California Health & Wellness Alerts for Providers

Questions and Answers for California Health & Wellness Plan Network Providers

Due to the rapidly changing environment as a result of COVID-19, the information included in this section is intended to serve as a guide for COVID-19-related information. This information and guidance is in response to the current state of COVID-19 and is subject to change, and may be retired at a future date. Unless stated otherwise, special coverage and waivers stated herein expire when the public emergency period ends. This section shall be updated as new information and guidance becomes available; however, providers should continue to refer to the Department of Health Care Services (DHCS) website for the most up-to-date information.

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COVID-19 Alerts

Recent and time-sensitive news concerning COVID-19

COVID-19 Alerts

COVID-19 Therapeutic and Vaccine FAQs

What you need to know about current treatment
 

Therapeutic and Vaccine FAQs

COVID-19 Trainings & Webinars

Notices about COVID-19-related trainings and webinar sessions

COVID-19 Training

COVID-19 General Information

What's covered, how to bill for treatment, telehealth guidance, and more

General FAQs

Updated October 13, 2023


Information throughout the FAQs has been updated to reflect current guidance and information, including the following sections.

COVID-19 Therapeutic and Vaccine FAQs

  • COVID-19 Vaccines (updated)

COVID-19 Therapeutic and Vaccine FAQs

What you need to know about current treatment

Is there provider support for questions about COVID-19 testing and treatment?

All California health care providers can get confidential consultation support through the COVID-19 Therapeutics Warmline (PDF) managed by the University of California, San Francisco (USCF) National Clinical Consultation Center (NCCC). Providers of any experience level can speak with a clinician or pharmacist:

  • Call 866-268-4233 (866-COVID-CA), Monday–Friday, 6:00 a.m.–5:00 p.m. After-hours voice mail messages are returned the next business day.
  • This support is in real-time and at no cost.
  • No protected health information (PHI) is collected.

What resources are available about COVID-19 outpatient therapeutics?

Videos and resources are available from the Department of Health and Human Services' Administration for Strategic Preparedness & Response (ASPR). The website covers the following topics and more:

  • Compare COVID-19 Therapeutics and Patient Requirements
  • Find, Order and Report COVID-19 Therapeutics
  • Learn About COVID-19 Therapeutics
  • Share Resources with Patients and Other Health Care Providers

The following videos are available through ASPR and cover:

  • ASPR and the COVID Response
  • Overview: COVID-19 Therapeutics
  • COVID-19 Therapeutics Distribution
  • Separate videos about therapeutics for: Paxlovid, Lagevrio, and Veklury

Note: The U.S. Food and Drug Administration (FDA) announced on January 26, 2023, that Evusheld is no longer authorized for emergency use in the United States against developing variants of the COVID-19 virus.

Additional resources

The Office of Communications for the California Department of Public Health (CDPH) has different material to download and print – from graphics and hand-outs to social messaging in English and Spanish. The goal is to educate patients and encourage use of COVID-19 therapeutics to treat symptoms before they become severe.

How to dispel misinformation about treatments

See the CDPH COVID-19 Therapeutics Myths and Facts sheet (PDF). It covers questions, such as:

  • I don't need treatment for mild-to-moderate illness.
  • I'm not high risk.
  • Treatments have serious side effects.
  • Rebound caused by treatments is common and can be dangerous.

Where can I get information for my patients about the COVID-19 Test to Treat Program?

More information about the Test to Treat Program can be found on the CDPH website. Patients who have COVID-19 symptoms can be seen by a health care provider and get treatment at a Test to Treat site during the same visit, if needed.

  • This is available to adults and children over age 12.
  • Uninsured individuals can access testing and treatment services at no cost at OptumServe locations.

Is coping assistance offered to members impacted by COVID-19?

Members impacted by COVID-19 may contact MHN, our behavioral health administrator, for referrals to mental health counselors, local resources or telephonic consultations to help them cope with stress, grief, loss, or other trauma resulting from COVID-19. Members may contact MHN 24 hours a day, seven days a week at 800-227-1060, or the telephone number listed on the member's identification (ID) card.

Additional resources on how to mitigate the stress-related health outcomes anticipated with the COVID-19 emergency can be found at ACEs Aware.

Adverse Childhood Experiences (ACEs) resources and information for Medi-Cal can be found at California Department of Health Care Services Trauma Screenings and Trauma-Informed Care Provider Trainings.

What additional support does CHWP provide to enhance access to care for my patients?

CHWP offers many solutions to enhance access to care for your patients. These solutions supplement, but do not replace, the personal care you provide to your patients. Examples include:

  • The Nurse Advice Line – Available to members 24 hours a day at 800-893-5597 (TTY 711).
  • myStrength (tailored wellness resources to help members with mental health challenges) – If a member needs emergent or routine treatment services, call MHN at 888-327-0010 or myStrength.
  • CHWP Community Connect (findhelp) – A free online search service, allows members to find free and low cost social services.

As a health care provider, you play an integral role with COVID-19 vaccinations. For regular and frequent updates on the vaccine information and distribution in California, visit Vaccinate ALL 58.

Important! Enroll to get your California Immunization Information System (IIS) ID

The California Department of Public Health (CDPH) is overseeing the registration for the COVID-19 vaccination program in California. Program enrollment is currently focused on small physician practices who routinely vaccinate their patients as well as providers that are prioritized for vaccine allocation by local health departments.

Step 1: Get your IIS ID

Enroll in your local registry to receive your Immunization Information System (IIS) ID for enrollment in CalVax. County specific information is below.

Step 2: Enroll in myCAvax

Make sure you meet all the requirements (PDF) before enrolling. Use the Provider Enrollment Worksheet (PDF) to gather information needed ahead of time to complete enrollment in myCAvax.

Refer to the Readiness Checklist: Quick Start Guide (PDF) for additional steps to help providers onboard to the COVID-19 Vaccination Program.

More information that can help you share clear and accurate information about the COVID-19 vaccines and address common questions from patients can be found in the Communication Resources for Healthcare Providers and Staff from the Centers for Disease Control and Prevention (CDC).

Is there a current COVID-19 vaccination schedule?

The CDC develops age specific immunization schedules that give guidance based on age and medical conditions including dosage for different vaccines and interval periods between doses. Age and condition specific up-to date COVID-19 guidance is also available for:

Where can I find the latest guidance for the COVID-19 vaccine?

  Updated 10/13/23

What are the codes to report and bill the COVID-19 vaccines?

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

The following codes have been published; however, they will not be billable or payable until the specific vaccine receives official EUA approval or after the EUA is revoked.

Current vaccine-specific code sets with FDA EUAs
Code CPT Short Descriptor Labeler Name Vaccine/ Procedure Name
90480
(eff. September 11, 2023)
ADMN SARSCOV2 VACC 1 DOSE n/a Covid-19 vaccine administration
91318
(eff. September 11, 2023)
SARSCOV2 VAC 3MCG TRS-SUC Pfizer Pfizer-BioNTech COVID-19 Vaccine 2023-2024 Formula (Yellow Cap)
91319
(eff. September 11, 2023)
SARSCV2 VAC 10MCG TRS-SUC IM Pfizer Pfizer-BioNTech COVID-19 Vaccine 2023-2024 Formula (Blue Cap)
91320
(eff. September 11, 2023)
SARSCV2 VAC 30MCG TRS-SUC IM Pfizer COMIRNATY (COVID-19 Vaccine, mRNA) 2023-2024 Formula
91321
(eff. September 11, 2023)
SARSCOV2 VAC 25 MCG/.25ML IM Moderna Moderna COVID-19 Vaccine 2023-2024 Formula
91322
(eff. September 11, 2023)
SARSCOV2 VAC 50 MCG/0.5ML IM Moderna SPIKEVAX 2023-2024 Formula
91304
(eff. July 13, 2022)
SARS-COV2
5MCG/0.5ML IM
Novavax Novavax COVID-19 Vaccine ages 18+
0041A
(eff. July 13, 2022)
ADM SARSCOV2
5MCG/0.5ML First dose
Novavax Novavax COVID-19 Vaccine Administration ages 18+ – First Dose
0041B
(eff. July 13, 2022)
ADM SARSCOV2
5MCG/0.5ML Second dose
Novavax Novavax COVID-19 Vaccine Administration ages 18+ – First Dose
0044A
(eff. October 19, 2022)
ADM SARSCOV2
5MCG/0.5ML BST
Novavax Novavax Covid-19 Vaccine, Adjuvanted Administration - Booster
Prior vaccine-specific code sets with FDA Emergency Use Authorization revoked
Code CPT Short Descriptor Labeler Name Vaccine/ Procedure Name
91300
(EUA revoked 4/18/2023)
SARSCOV2 VAC
30MCG/0.3ML IM
Pfizer Pfizer-BioNTech COVID-19 Vaccine
0001A
(EUA revoked 4/18/2023)
ADM SARSCOV2 VAC
30MCG/0.3ML 1ST
Pfizer Pfizer-BioNTech COVID-19 Vaccine Administration – First Dose
0002A
(EUA revoked 4/18/2023)
ADM SARSCOV2 VAC
30MCG/0.3ML 2ND
Pfizer Pfizer-BioNTech COVID-19 Vaccine Administration – Second Dose
0003A
(EUA revoked 4/18/2023)
ADM SARSCOV2 VAC
30MCG/0.3ML 3RD
Pfizer Pfizer-BioNTech COVID-19 Vaccine Administration – Third Dose
0004A*
(EUA revoked 4/18/2023)
ADM SARSCOV2
30MCG/0.3ML BST
Pfizer Pfizer-BioNTech COVID-19 Vaccine Administration – Booster
91305
(EUA revoked 4/18/2023)
SARSCOV2 VAC
30MCG TRS-SUCR
Pfizer Pfizer-BioNTech Covid-19 Vaccine Pre-Diluted (Gray Cap)
0051A
(EUA revoked 4/18/2023)
ADM SARSCV2
30MCG TRS-SUCR 1
Pfizer Pfizer-BioNTech Covid-19 Vaccine Pre-Diluted (Gray Cap) Administration - First dose
0052A
(EUA revoked 4/18/2023)
ADM SARSCV2
30MCG TRS-SUCR 2
Pfizer Pfizer-BioNTech Covid-19 Vaccine Pre-Diluted (Gray Cap) Administration - Second dose
0053A
(EUA revoked 4/18/2023)
ADM SARSCV2
30MCG TRS-SUCR 3
Pfizer Pfizer-BioNTech Covid-19 Vaccine Pre-Diluted (Gray Cap) Administration - Third dose
0054A*
(EUA revoked 4/18/2023)
ADM SARSCV2
30MCG TRS-SUCR B
Pfizer Pfizer-BioNTech Covid-19 Vaccine Pre-Diluted (Gray Cap) Administration - Booster
91307
(EUA revoked 4/18/2023)
SARSCOV2
10MCG/0.2ML TRS-SUCR
Pfizer Pfizer-BioNTech Covid-19 Vaccine

Pediatric
0071A
(EUA revoked 4/18/2023)
ADM SARSCOV2 VAC
10MCG/0.2ML TRS-SUCR 1
Pfizer Pfizer-BioNTech Covid-19 Vaccine

Pediatric Administration – First Dose
0072A
(EUA revoked 4/18/2023)
ADM SARSCOV2 VAC
10MCG/0.2ML TRS-SUCR 2
Pfizer Pfizer-BioNTech Covid-19 Vaccine

Pediatric Administration – Second Dose
0073A
(EUA revoked 4/18/2023)
ADM SARSCOV2 VAC
10 MCG/0.2ML TRS-SUCR 3
Pfizer Pfizer-BioNTech Covid-19 Vaccine Pediatric Administration – Third Dose
0074A
(EUA revoked 4/18/2023)
ADM SARSCOV2 VAC
10MCG/0.2ML TRS-SUCR B
Pfizer Pfizer-BioNTech Covid-19 Vaccine Pediatric Administration

Single booster dose
91308
(EUA revoked 4/18/2023)
SARSCOV2
3MCG/0.2ML TRS-SUCR
Pfizer Pfizer-BioNTech Covid-19 Vaccine

Pediatric ages 6 months–4 years
0081A
(EUA revoked 4/18/2023)
ADM SARSCOV2 VAC
3MCG/0.2ML TRS-SUCR 1
Pfizer Pfizer-BioNTech Covid-19 Vaccine

Pediatric Administration ages 6 months–4 years
0082A
(EUA revoked 4/18/2023)
ADM SARSCOV2 VAC
3MCG/0.2ML TRS-SUCR 2
Pfizer Pfizer-BioNTech Covid-19 Vaccine

Pediatric Administration ages 6 months–4 years
0083A
(EUA revoked 4/18/2023)
ADM SARSCOV2 VAC
3MCG/0.2ML TRS-SUCR 3
Pfizer Pfizer-BioNTech Covid-19 Vaccine

Pediatric Administration ages 6 months–4 years
91301
(EUA revoked 4/18/2023)
SARSCOV2 VAC
100MCG/0.5ML IM
Moderna Moderna COVID-19 Vaccine
0011A
(EUA revoked 4/18/2023)
ADM SARSCOV2 VAC
100MCG/0.5ML 1ST
Moderna Moderna COVID-19 Vaccine Administration – First Dose
0012A
(EUA revoked 4/18/2023)
ADM SARSCOV2 VAC
100MCG/0.5ML 2ND
Moderna Moderna COVID-19 Vaccine Administration – Second Dose
0013A
(EUA revoked 4/18/2023)
ADM SARSCOV2 VAC
100MCG/0.5ML 3RD
Moderna Moderna COVID-19 Vaccine Administration – Second Dose
91303
(EUA revoked 4/18/2023)
SARSCOV2 VAC AD26 .5ML IM Janssen Janssen COVID-19 Vaccine
91306*
(EUA revoked 4/18/2023)
SARSCOV2 VAC
50MCG/0.25ML IM
Moderna Moderna COVID-19 Vaccine (Low Dose)
0064A*
(EUA revoked 4/18/2023)
ADM SARSCOV2
50MCG/0.25ML BST
Moderna Moderna COVID-19 Vaccine (Low Dose) Administration – Booster
0091A
(EUA revoked 4/18/2023)
ADM SARSCOV2
50MCG/0.5ML 1ST
Moderna Moderna COVID-19 Vaccine Administration

Pediatric ages 6–11
0092A
(EUA revoked 4/18/2023)
ADM SARSCOV2
50MCG/0.5ML 2ND
Moderna Moderna COVID-19 Vaccine Administration

Pediatric ages 6–11
0093A
(EUA revoked 4/18/2023)
ADM SARSCOV2
50MCG/0.5ML 3RD
Moderna Moderna COVID-19 Vaccine Administration

Pediatric ages 6–11
0113A
(EUA revoked 4/18/2023)
AMD SARSCOV2
25MCG/0.25ML 3RD
Moderna Moderna COVID-19 Vaccine Administration

Pediatric ages 6–11
91309
(EUA revoked 4/18/2023)
SARSCOV2 VAC
50MCG/0.5ML IM
Moderna Moderna COVID-19 Vaccine - Booster
0094A
(EUA revoked 4/18/2023)
ADM SARSCOV2
50MCG/0.5ML BST
Moderna Moderna COVID-19 Vaccine Administration – Booster
91311
(EUA revoked 4/18/2023)
SARSCOV2
25 MCG/0.25 ML IM
Moderna Moderna COVID-19 Vaccine
0111A
(EUA revoked 4/18/2023)
IMM ADMN SARSCOV2
25 MCG/0.25 ML First dose
Moderna Moderna COVID-19 Vaccine Administration – First Dose
0112A
(EUA revoked 4/18/2023)
IMM ADMN SARSCOV2
25 MCG/0.25 ML Second dose
Moderna Moderna COVID-19 Vaccine Administration – Second Dose
91312
(EUA revoked 9/12/2023)
SARSCOV2 VAC
30MCG/0.3ML TRS-SUCR
Pfizer Pfizer-BioNTech Covid-19 Vaccine – Booster
0124A
(EUA revoked 9/12/2023)
ADM SARSCV2
30MCG/0.3ML TRS-SUCR 3
Pfizer Pfizer-BioNTech Covid-19 Vaccine Administration – Booster
91315
(EUA revoked 9/12/2023)
SARSCOV2 VAC
10MCG/0.2ML TRS-SUCR
Pfizer Pfizer-BioNTech Covid-19 Vaccine – Booster ages 5 years – 11 years
0154A
(EUA revoked 9/12/2023)
ADM SARSCV2
10MCG/0.2ML TRS-SUCR 3
Pfizer Pfizer-BioNTech Covid-19 Vaccine Administration – Booster ages 5 years – 11 years
91317
(EUA revoked 9/12/2023)
SARSCOV2 VAC BVL 3MCG/0.2ML Pfizer Pfizer-BioNTech COVID-19 Vaccine, Bivalent Product ages 6 months through 4 years (Maroon cap)
0173A
(EUA revoked 9/12/2023)
ADM SARSCV2 BVL 3MCG/0.2ML 3 Pfizer Pfizer-BioNTech Covid-19 Pediatric Vaccine (ages 6 months through 4 years) (Maroon cap) Administration - Third Dose
91313
(EUA revoked 9/12/2023)
SARS-COV2
50MCG/0.5 ML IM
Moderna Moderna COVID-19 Vaccine – Bivalent Booster
0134A
(EUA revoked 9/12/2023)
ADM SARSCOV2 VAC
50MCG/0.5ML BST
Moderna Moderna COVID-19 Vaccine Administration – Bivalent Booster
91314
(EUA revoked 9/12/2023)
SARS-COV2
25MCG/0.25 ML IM
Moderna Moderna COVID-19 Vaccine – Bivalent Booster ages 6 years – 11 years
0144A
(EUA revoked August 31, 2022)
ADM SARSCOV2 VAC
25MCG/0.25ML BST
Moderna Moderna COVID-19 Vaccine Administration – Bivalent Booster ages 6 years – 11 years
91316
(EUA revoked 9/12/2023)
SARSCOV2 VAC BVL 10MCG/0.2M Moderna Moderna COVID-19 Vaccine, Bivalent Product ages 6 months through 5 years
(Dark pink cap and a label with a yellow box)
0164A
(EUA revoked 9/12/2023)
ADM SRSCV2 BVL 10MCG/0.2ML B Moderna Moderna COVID-19 Vaccine, Bivalent
ages 6 months through 5 years
(Dark pink cap and label with a yellow box) Administration – Booster Dose
91303
(EUA revoked 6/1/2023)
SARSCOV2 VAC
AD26 .5ML IM
Janssen Janssen COVID-19 Vaccine
0031A
(EUA revoked 6/1/2023)
ADM SARSCOV2
VAC AD26 .5ML
Janssen Janssen COVID-19 Vaccine Administration
0034A
(EUA revoked 6/1/2023)
ADM SARSCOV2
VAC AD26 .5ML B
Janssen Janssen COVID-19 Vaccine Administration – Booster

What are the reporting requirements for the COVID-19 vaccine?

Providers must record details of the vaccination into their system of record within 24 hours, and into the applicable public health system within 72 hours.

  Updated 10/13/23

How will the COVID-19 vaccine be covered for members?

Similar to other preventive immunizations, the COVID-19 vaccines are offered at no cost to members. In addition:

COVID-19 General Information

What's covered, how to bill for treatment, telehealth guidance, and more

Effective February 11, 2023, Health and Human Services (HHS) Secretary Xavier Becerra renewed the COVID-19 Public Health Emergency for a final time with a 90-day notice. This extends flexibilities and funding tied to the public health emergency (PHE) to continue through May 11, 2023, at which time the PHE will expire. California state law adds six months to the federal PHE requirements on health plans to continue covering COVID-19 tests, vaccines and therapeutics from any licensed provider (in- or out-of-network) with no prior authorization or enrollee cost sharing.

Does CHWP allow access to telehealth services to increase access to care? And what is the reimbursement rate?

To limit members' risk of COVID-19 infection, CHWP encourages use of telehealth to deliver care when medically appropriate and capable through telehealth modalities for covered services.

CHWP's coverage for telehealth services is in accordance with regulatory requirements, and will be reimbursed whether the telehealth service is delivered via audio/video technology or via audio-only technology (when deemed medically appropriate for the patient's medical condition).

  • Federally Qualified Health Centers (FQHCs), Regional Health Centers (RHCs), and Indian Health Service (IHS) Clinics – CHWP's Medi-Cal coverage for telehealth services will follow guidelines released by the Department of Health Care Services (DHCS), which includes virtual/telephonic visits consistent with in person visits.
  • CHWP will reimburse fee-for-service providers the same contracted rate for the procedure code billed, whether service is provided in person or through telehealth technology. Billing must be in accordance with CHWP requirements in order to receive payment parity.
  • Services that cannot be appropriately delivered remotely are not eligible for telehealth coverage and reimbursement.
  • Capitated physician groups or independent practice associations (IPAs) are required to support, cover and enable telehealth services and to abide by regulatory requirements for coverage and payment of telehealth services as outlined above. Claims processing risk will follow the in-person location place of service where the service would have been delivered in lieu of telehealth.

In addition to telehealth services offered through our network of providers, CHWP has expanded access to telehealth services through third parties.

How do I bill for telehealth services?

Use appropriate American Medical Association (AMA) CPT and HCPCS codes most descriptive for the service delivered:

  • Provider should bill for telehealth services in accordance with the DHCS Provider Manual Telehealth requirements (PDF).
  • Use appropriate modifiers, when applicable – excluding FQHC/RHCs
    • Modifier 95 (Synchronous, interactive audio and telecommunications systems), OR
    • Modifier GQ (Asynchronous store and forward telecommunications systems)

Examples of benefits or services not appropriate for telehealth delivery:

Below are some examples (not exhaustive) of benefits or services that would not be appropriate for delivery via a telehealth modality:

  • Performed in an operating room or while the patient is under anesthesia.
  • Require direct visualization or instrumentation of bodily structures.
  • Involve sampling of tissue or insertion/removal of medical device.
  • Require the in-person presence of the patient for any reason.

Capitated Physician Groups/IPAs:

Capitated physician groups or IPAs are required to support, cover and enable telehealth services and to abide by regulatory requirements for coverage and payment of telehealth services as outlined above.

What is CHWP's strategy to support telehealth services for providers and members?

CHWP is committed to supporting your relationship with your patients. We continuously encourage members to first take advantage of the telehealth services provided by their primary care provider before considering CHWP's contracted vendors.

What additional telehealth options are available to my patients?

CHWP offers additional telehealth services to enhance access to care for your patients. These services supplement, but do not replace, the personal care you provide to your patients. Effective August 10, 2023, Teladoc will be CHWP’s select telehealth service provider.

Providers can also refer to Telehealth Platforms for Providers for a variety of telehealth platforms that optimize the availability of telehealth capabilities to our providers. These platforms accommodate most medical conditions, including COVID-19, and allow for a compliant way to administer health care services to your patients.

What support will Teladoc provide to me if my patients use them?

Teladoc supports the PCP and their relationship with their patient. Teladoc services include:

  • Visit summaries sent to the PCP for close communication and continuity of care, at the member’s request.
  • Referring patients back to the assigned PCP for follow-up appointments.
  • Prescribing of non-scheduled, non-lifestyle medications.
  • Availability of the member’s medical records through the Teladoc app.

On November 8, 2021, Governor Newsom signed California Senate Bill 510 ("SB 510") impacting the Medi-Cal line of business. This bill became law effective January 1, 2022, and addresses, among other things, reimbursement for COVID-19 diagnostic and screening testing.

California Health & Wellness Plan (CHWP) has analyzed SB 510 and has taken appropriate steps to comply; however, litigation brought by the California Association of Health Plans and the Association of California Life and Health Insurance Companies challenged the constitutionality of the retroactive application of Health & Safety Code 1342.2 and Insurance Code 10110.7, respectively, and on July 5, 2022, the Superior Court of California in Los Angeles County granted a preliminary injunction enjoining the California Department of Managed Health Care from enforcing the retroactive application of SB 510 during the pendency of the lawsuit.

We are aware of the Court's final judgment in the litigation on June 27, 2023, which reversed the injunction and held that SB 510 will apply to COVID-19 testing with dates of service prior to January 1, 2022. An appeal of the Court's decision is pending. In the interim, CHWP is working to address affected 2020-2021 claims previously denied to the at-risk delegates. Delegated at-risk entities can submit to their CHWP contracting representative their detailed requests for reimbursement for delegate paid COVID testing claims for dates of service prior to 2022. Requests, including claim level detail, must be received by CHWP prior to September 1, 2023, to be considered for reimbursement.

Unless the parties' contract explicitly directs otherwise, for dates of service January 1, 2022, and forward, CHWP has not and will not cap-deduct any Medi-Cal costs of COVID-19 testing from capitation payments and CHWP ceased the redirection of testing providers for their reimbursement.

As a reminder, vaccination administration costs will continue to be reimbursed by DHCS. For more information, see "How will the COVID-19 vaccine be covered for members?" under the COVID-19 Vaccines section.

Is CHWP requiring prior authorization, precertification, prior notification, or step therapy protocols for COVID-19 screening and testing? Will cost shares be applied?

CA state law will continue benefit coverage requirements as is for six months after the federal Public Health Emergency expires on May 11, 2023. CHWP will continue not applying member cost shares or requiring prior authorization, precertification, prior notification, or step therapy protocols for COVID-19 screening and testing services at this time for both network and out of network providers. The primary purpose of the visit must be for screening for COVID-19 testing for the waivers to apply, as identified by the primary diagnosis being for COVID-19 screening.

What billing codes should be used to bill for COVID-19 testing?

CMS updated the list of valid HCPCS codes used for COVID-19 related testing and billing effective May 12, 2023. Claims after that date must reflect a valid HCPCS code for reimbursement.

Specimen Collection – Valid codes:

  • HCPC C9803 - Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]).
  • CPTs 99000, 99001, or 99211 when billed with a COVID-19 related diagnosis code.

Invalid specimen collection codes for billing dates of service on or after May 12, 2023:

  • HCPCS G2023
  • HCPCS G2024

Active Virus Testing – Valid codes:

  • HCPCS U0001 - For CDC developed tests only: 2019-nCoV Real-Time RT-PCR Diagnostic Panel.
  • HCPCS U0002 - For all other commercially available tests: 2019-nCoV Real-Time RT-PCR Diagnostic Panel.
  • CPT 87635 - (effective March 13, 2020): 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. The industry standard for reporting of novel coronavirus tests across the nation's health care system.
  • CPT 0202U (effective May 20, 2020): Infectious disease (bacterial or viral respiratory tract infection), pathogen specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected.
  • CPT 0223U (effective June 25, 2020) Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected.
  • CPT 87426 (effective June 25, 2020) Infectious agent antigen detection by immunoassay technique, (eg, 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, SARS-CoV-2 [COVID-19]).
  • CPT 0225U (effective September 8, 2020) Infectious disease (bacterial or viral respiratory tract infection) pathogen-specific DNA and RNA, 21 targets, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), amplified probe technique, including multiplex reverse transcription for RNA targets, each analyte reported as detected or not detected.
  • HCPC 0226U (effective September 8, 2020) Surrogate viral neutralization test (sVNT), severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]), ELISA, plasma, serum.
  • CPT 0240U (effective October 6, 2020) Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 3 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B), upper respiratory specimen, each pathogen reported as detected or not detected.
  • CPT 0241U (effective October 6, 2020) Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 4 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B, respiratory syncytial virus [RSV]), upper respiratory specimen, each pathogen reported as detected or not detected.
  • CPT 87636 (effective October 6, 2020) Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) and influenza virus types A and B, multiplex amplified probe technique.
  • CPT 87637 (effective October 6, 2020) 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
  • CPT 87811 (effective October 6, 2020) Infectious agent antigen detection by immunoassay with direct optical (i.e., visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]).
  • CPT 87913 (effective February 21, 2022) Infectious agent genotype analysis by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), mutation identification in targeted region(s).

Invalid active virus testing codes for billing dates of service on or after May 12, 2023:

  • HCPCS U0003
  • HCPCS U0004
  • HCPCS U0005 (Note: This code was not covered by Medi-Cal prior to May 12, 2023, as well)

Antibody (serologic) Testing

  • CPT 86318 (Medi-Cal only) Immunoassay for infectious agent antibody(ies), qualitative or semi quantitative, single step method (eg, reagent strip); (EXISTING PARENT CODE NOT SPECIFIC TO COVID 19)
  • CPT 86328 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), (Coronavirus disease [COVID-19]), (For severe acute respiratory syndrome, coronavirus 2 [SARS-CoV-2] [Coronavirus, disease {COVID-19}] antibody testing using multiple-step method, use 86769)
  • CPT 86769 Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) (For severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [Coronavirus disease {COVID-19}] antibody testing using single step method, use 86328)
  • CPT 0224U (effective June 25, 2020) Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), includes titer(s), when performed.
  • CPT 86408 (effective August 10, 2020) Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); screen.
  • CPT 86409 (effective August 10, 2020) Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); titer.
  • CPT 86413 (effective September 8, 2020) Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) antibody, quantitative.

CDC Antibody Testing Guidance: See the Interim Guidelines for COVID-19 Antibody Testing

What diagnosis codes should be used to bill for services related to COVID-19 screening and testing?

For complete and up-to-date diagnosis coding for COVID-19, visit the CDC National Center for Health Statistics website.

The following diagnosis codes can be used to bill for screening and testing services related to COVID-19.

  • Z11.52 – Encounter for screening for COVID-19.
  • Z20.822 – Contact with and (suspected) exposure to COVID-19.

Can providers balance bill members for fees related to screening and testing for COVID-19?

Balance billing is strictly prohibited by state and federal law and CHWP's PPA. Providers may not bill members for any fees related to screening and testing for COVID-19.

Are there changes to the appeal process for Medi-Cal members during the public health emergency (PHE)?

Through the duration of the PHE, whenever a member's appeal involves the termination, suspension or reduction of previously authorized services, CHWP must provide Aid Paid Pending (APP) when an appeal and state fair hearing is filed timely. CHWP is not allowed to seek reimbursement or payment for the additional days of services furnished during this period.

Is CHWP waiving prior authorizations for COVID-19 related therapeutics?

As of September 25, 2022, therapeutics approved or granted emergency use authorization by the federal Food and Drug Administration (FDA) for the treatment of COVID-19 when prescribed or furnished by a licensed health care provider acting within their scope of practice and the standard of care will be provided with no member cost share for Medi-Cal members.

CA state law will continue benefit coverage requirements as is for six months after the federal Public Health Emergency expires on May 11, 2023.

For admissions and/or dates of service prior to June 1, 2021, CHWP and its delegated entities will waive prior authorizations for COVID-19 related treatments for all Medi-Cal members. Inpatient admission notification is still required as soon as possible to CHWP and the member's assigned delegated participating physician group (PPG) or IPA, if available. After June 1, 2021, normal prior authorization guidelines will apply.

What COVID-19 ICD-10 diagnoses codes are approved for use in treatment?

  • U07.1: 2019-nCoV - Confirmed by lab testing (effective April 1, 2020)
  • M35.81: Multisystem Inflammatory Syndrome (MIS) (effective January 1, 2021)

Does CHWP cover monoclonal antibody infusion treatment for COVID-19?

For dates of service prior to June 1, 2021, COVID-19 monoclonal antibody treatments available under an FDA Emergency Use Authorization (EUA) are covered benefits with no cost share or prior authorization required. The medications are available from the federal government at no cost to providers.

  • From June 1, 2021 to September 24, 2022, normal cost shares and prior authorization guidelines, if any, applied.
  • As of September 25, 2022, there is no prior authorization or cost shares for commercial and Medi-Cal members.
  • CA state law will continue benefit coverage requirements as is for six months after the federal Public Health Emergency expires on May 11, 2023.

The following codes have been published, however, they are not billable or payable until after the specific treatment received official EUA approval.

Current monoclonal antibody treatments with FDA EUAs
Code CPT Short Descriptor Labeler Name Vaccine/Procedure Name
Q0249
(eff. June 24, 2021)
Tocilizumab for COVID-19 Genentech Injection, tocilizumab, for hospitalized adults and pediatric patients (ages 2 years and older) with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, 1 mg
M0249
(eff. June 24, 2021)
Adm Tocilizu COVID-19 1st Genentech Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (ages 2 years and older) with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, first dose
M0250
(eff. June 24, 2021)
Adm Tocilizu COVID-19 2nd Genentech Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (ages 2 years and older) with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, second dose
Q0220
(eff. December 8, 2021)
Tixagevimab & Cilgavimab (EVUSHELD), 300mg AstraZeneca Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available covid-19 vaccine is not recommended due to a history of severe adverse reaction to a covid-19 vaccine(s) and/or covid-19 vaccine component(s), 300 mg
Q0221
(eff. February 24, 2022)
Tixagevimab & Cilgavimab (EVUSHELD), 600mg AstraZeneca Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available covid-19 vaccine is not recommended due to a history of severe adverse reaction to a covid-19 vaccine(s) and/or covid-19 vaccine component(s), 600 mg
M0220
(eff. December 8, 2021)
Tixagevimab & Cilgavimab (EVUSHELD) Admin AstraZeneca Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available covid-19 vaccine is not recommended due to a history of severe adverse reaction to a covid-19 vaccine(s) and/or covid-19 vaccine component(s), includes injection and post administration monitoring
M0221
(eff. December 8, 2021)
Tixagevimab & Cilgavimab (EVUSHELD) Admin Home AstraZeneca Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available covid-19 vaccine is not recommended due to a history of severe adverse reaction to a covid-19 vaccine(s) and/or covid-19 vaccine component(s), includes injection and post administration monitoring in the home or residence; this includes a beneficiary's home that has been made provider-based to the hospital during the covid-19 public health emergency
Prior treatments with FDA Emergency Use Authorization revoked
Code CPT Short Descriptor Labeler Name Vaccine/Procedure Name
Q0239*
(FDA's EUA ended April 16, 2021)
bamlanivimab-xxxx
(FDA's EUA ended April 16, 2021)
Eli Lilly Injection, bamlanivimab, 700 mg
M0239
(FDA's EUA ended April 16, 2021)
bamlanivimab-xxxx infusion
(FDA's EUA ended April 16, 2021)
Eli Lilly Intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring
Q0240
(eff. July 30, 2021; FDA's EUA ended January 24, 2022)
Casirivi and imdevi 600mg Regeneron Injection, casirivimab and imdevimab, 600 mg
M0240
(eff. July 30, 2021; FDA's EUA ended January 24, 2022)
Casiri and imdev repeat Regeneron Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring, subsequent repeat doses
M0241
(eff. July 30, 2021; FDA's EUA ended January 24, 2022)
Casiri and imdev repeat hm Regeneron Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring in the home or residence. This includes a beneficiary's home, subsequent repeat doses
Q0243*
(FDA's EUA ended January 24, 2022)
casirivimab and imdevimab Regeneron Injection, casirivimab and imdevimab, 2400 mg
Q0244
(eff. June 3, 2021; FDA's EUA ended January 24, 2022)
casirivimab and imdevimab Regeneron Injection, casirivimab and imdevimab, 1200 mg
M0243
(FDA's EUA ended January 24, 2022)
casirivi and imdevi infusion Regeneron Intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring
M0244
(eff. May 6, 2021; FDA's EUA ended January 24, 2022)
casirivi and imdevi infusion home Regeneron Intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring in the home or residence
Q0245*
(FDA's EUA ended January 24, 2022)
bamlanivimab and etesevimab

Eli Lilly

Injection, bamlanivimab and etesevimab, 2100 mg
M0245
(FDA's EUA ended January 24, 2022)
bamlan and etesev infusion Eli Lilly Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring
M0246
(FDA's EUA ended January 24, 2022)
bamlan and etesev infusion home Eli Lilly Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring in the home or residence
Q0247
(eff. May 26, 2021 – ended April 5, 2022)
Sotrovimab GSK Injection, sotrovimab, 500 mg
M0247
(eff. May 26, 2021 – ended April 5, 2022)
Sotrovimab infusion GSK Intravenous infusion, sotrovimab, includes infusion and post administration monitoring
M0248
(eff. May 26, 2021 – ended April 5, 2022)
Sotrovimab inf, home admin GSK Intravenous infusion, sotrovimab, includes infusion and post administration monitoring in the home or residence
Q0222
(eff. February 11, 2022; FDA's EUA ended November 30, 2022)
Bebtelovimab 175 mg Eli Lilly Injection, bebtelovimab, 175 mg
M0222
(eff. February 11, 2022 FDA's EUA ended November 30, 2022)
Bebtelovimab injection admin Eli Lilly Intravenous injection, bebtelovimab, includes injection and post administration monitoring
M0223
(eff. February 11, 2022 FDA's EUA ended November 30, 2022)
Bebtelovimab injection admin, home Eli Lilly Intravenous injection, bebtelovimab, includes injection and post administration monitoring in the home or residence; this includes a beneficiary's home that has been made provider-based to the hospital during the covid-19 public health emergency

* medication code not payable

Per DHCS clarification, the infusion administration is not carved out of the managed Medi-Cal program. The medication and infusion's administration fee is billable to the appropriate payor based on CHWP's existing division of financial responsibility with the capitated physician group/IPA. Medication that is available free from the federal government is not reimbursable. See a list of infusion sites that offer monoclonal antibody infusion treatments (XLSX).


March 5, 2020

What you need to know about COVID-19 (updated, March 20, 2020)

Coronavirus Disease 2019 (COVID-19) is a new disease that causes respiratory illness in people and can spread from person to person. Though the risk of getting COVID-19 in the U.S. is low, learn how you can help keep yourself and others healthy.