California Health & Wellness Alerts for Providers

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.

• Alpine, Amador, Calaveras, Mariposa, Tuolumne Counties
• Other Counties

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:

• Children
• Adults
• Maternal

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

• Centers for Medicare & Medicaid Services (CMS) (PDF)
• California Department of Healthcare Services (DHCS) COVID-19 Vaccine Administration FAQs (PDF)
• Centers for Disease Control and Prevention (CDC) COVID-19 Vaccine FAQs

  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.

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:

• CA state law will continue benefit coverage requirements as is for six months after the federal Public Health Emergency expires on May 11, 2023. More information can be found at DHCS COVID-19 Vaccine Administration Provider FAQs.
• CHWP will not be able to process these claims.
• Providers must submit claims for the COVID-19 vaccine to DHCS through at least December 31, 2023. Refer to these DHCS resources for more information.
  • COVID-19 Vaccine Administration: Real-Time NCPDP D.0 Pharmacy Claims Can Be Submitted
  • COVID-19 Vaccine Administration: Medical and Outpatient Claims Can Be Submitted
  • COVID-19 Vaccine Administration: Real-Time NCPDP D.0 Pharmacy Claims Submission Reminders
  • COVID-19 Vaccine Administration: Real-Time RTIP Pharmacy Claims Can Be Submitted
  • Medi-Cal List of Contract Drugs: COVID-19 Vaccines Pfizer-BioNTech and Moderna Added

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.

* 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).