FAQs for COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment and Vaccine Administration

The HRSA COVID-19 Uninsured Program aligns claims reimbursement for monoclonal antibody therapy with the CMS guidance issued on November 10, 2020. Per CMS’s Medicare Monoclonal Antibody COVID-19 Infusion Program Instruction, “During the COVID-19 public health emergency (PHE), Medicare will cover and pay for these infusions the same way it covers and pays for COVID-19 vaccines (when furnished consistent with the EUA).” Information regarding coding and pricing can be found in the Medicare Monoclonal Antibody COVID-19 Infusion Program Instruction (PDF - 70 KB).

Health care providers who have conducted COVID-19 testing for uninsured individuals, provided treatment to uninsured individuals with a primary COVID-19 diagnosis on or after February 4, 2020, or administered an FDA-authorized or licensed COVID-19 vaccine to uninsured individuals, can request claims reimbursement through the program electronically and are reimbursed generally at Medicare rates, subject to available funding. Steps will involve: enrolling as a provider participant, checking patient eligibility, submitting patient information, submitting claims, and receiving payment via direct deposit.

To participate, providers must attest to the following at registration:

• They have checked for health care coverage eligibility and confirmed that the patient is uninsured. They have verified that the patient does not have health care coverage, and no other payer will reimburse them for COVID-19 testing and/or care or vaccine administration for that patient.
• They will accept defined program reimbursement as payment in full.
• They will agree not to balance bill the patient.
• They will agree to program terms and conditions and may be subject to post-reimbursement audit review.

All claims submitted must be complete and final, and no interim bills or corrected claims are accepted. There are no adjustments to payment once claims reimbursements are made.

Eligible providers began enrolling in the program on April 27, 2020, and submitting claims on May 6, 2020. The majority of claims are reimbursed within 30 days.

Information on claims submission can be found at: COVID-19 Claims Reimbursement.

Providers should submit the following patient information as part of the HRSA COVID-19 Uninsured Program:

• First and last name
• Date of birth
• Gender
• *SSN and state of residence; if not available, enter state identification / driver's license
• Date of service for professional, institutional outpatient services.
• Date of admission and date of discharge for institutional inpatient services.
• **Address
• Middle initial (optional)
• Patient account number (optional)

* A SSN and state of residence, or state identification / driver’s license is needed only for the purpose of verifying insurance status. If a SSN and state of residence, or state identification / driver’s license is not submitted, you will need to attest that you attempted to capture this information before submitting a claim and the patient did not have this information at the time of service, or that you did not have direct contact with the patient and thus did not have an opportunity to attempt to capture this information.

**If the individual is unable or unwilling to provide their address, please add the address of the facility where the care was provided or other location that may be appropriate (e.g., shelter).

For professional and institutional outpatient – Temporary member ID is valid for 120 days from date of service. Eligible claims can be submitted using the temporary member ID with date of service within the validity period. For example, if Patient A had a date of service of February 4, 2020, then the temporary ID assigned to her is valid from February 4, 2020, through June 3, 2020.

For institutional inpatient – Temporary member ID is valid from date of admission and expires 120 days from date of discharge. Eligible claims can be submitted using the temporary member ID with date of admission and date of discharge within the validity period. For example, if Patient B had a date of admission of February 4, 2020, and date of discharge of February 20, 2020, then the temporary member ID assigned to him is valid from February 4, 2020, through June 19, 2020. Note: If an uninsured individual was treated in the ER before being admitted as an inpatient, use the date of admittance to the ER as the inpatient admittance date.

Claims can still be submitted after the date of validity, but the temporary member ID must be eligible for the date of service or admittance.

No. All claims submissions and claims reimbursements must be submitted and remitted electronically.

No. These are claims reimbursements, not loans, to health care providers, and will not need to be repaid, provided applicable terms and conditions are met and except when it is later determined that the payments were to ineligible providers or for ineligible beneficiaries or costs.

Reimbursement pricing and policies under this program for eligible services, as determined by HRSA (subject to adjustment as may be necessary), are described below.

• Reimbursement is based on the current year Medicare fee schedule rates except where otherwise noted.
• Publication of new codes and updates to existing codes is made in accordance with published CMS guidance.
• For any new codes where a CMS published rate does not exist, claims are held until CMS publishes corresponding reimbursement information.
• Claims submitted electronically for professional services are priced as follows:
  • Services are priced with current-year CMS pricing with geographic adjustments, as applicable.
  • If no geographic adjustments are applicable, services are priced with current-year CMS national pricing.
  • COVID-19 testing and specimen collection procedures are priced in accordance with CARES Act (PDF) requirements and rates published in CMS interim final rules.
• Claims submitted electronically for facility services are generally priced according to traditional Medicare reimbursement, examples of exceptions are noted below:
  • For purposes of this program, facility reimbursement based on IPPS does not include the 20% increase to the DRG weight for COVID-19 diagnoses U07.1 and B97.29 authorized by Section 3710 of the Cares Act.
  • For purposes of this program, reimbursement rates for facilities not paid on IPPS [Critical Access Hospitals (CAHs), Rural Health Clinics (RHCs), Children’s Hospitals, and PPS Exempt Cancer Hospitals] are not updated after February 4, 2020.
  • Home health services are priced based on a per-visit methodology by service type as established by the program:
    • All Medicare-eligible service categories: PT/OT/ST - $90
    • Nursing services – skilled nursing - $90
    • Nursing services – licensed practical nurse - $60
    • Medical social services - $90
    • Home health aide - $30
    • Home infusion therapy – PICC/midline supplies $70, PICC/midline placement $110
• For purposes of this program, the following rates apply for reimbursement of ambulance claims with a primary diagnosis of COVID-19:
  • Ground ambulance: facility price of $350 per claim; professional claims price at current year CMS pricing with geographic adjustments as applicable
  • Water ambulance: facility price of $350 per claim; professional claims price at current year CMS pricing with geographic adjustments as applicable
  • Air ambulance: facility price of $2,300 per claim; professional claims price at current year CMS pricing with geographic adjustments as applicable
• The dispensing fee for FDA-licensed or authorized outpatient antiviral drugs for treatment of COVID-19 is priced at $12 without geographic adjustment.

FDA-licensed or authorized vaccine administration fees are priced based on national Medicare rates and are outlined below. For guidance on eligibility and billing for vaccine administration, refer to the Centers for Disease Control and Prevention (CDC) and Centers for Medicare & Medicaid Services (CMS) websites.

• For dates of service through March 14, 2021:
  • Administration of the final dose of a COVID-19 vaccine requiring a series of two or more doses - $28.39
  • Administration of the first dose of a COVID-19 vaccine requiring a series of two or more doses - $16.94
  • Administration of a single-dose COVID-19 vaccine - $28.39
• For dates of service on or after March 15, 2021:
  • Administration (per dose) of a COVID-19 vaccine - $40.00
  • For guidance on eligibility and billing for booster shots and additional doses of the vaccine, refer to the CDC website.
• For COVID-19 vaccinations administered in-home* with dates of service on or after June 8, 2021:
  • Administration (per dose) of a COVID-19 vaccine - $75.50
  • For guidance on eligibility and billing for booster shots and additional doses of the vaccine, refer to the CDC website.
  • *Note: In-home vaccine administration claims must be submitted with two codes to be eligible for reimbursement:
    • The first code must be one of the following:
      • Pfizer: 0001A, 0002A, 0003A, 0004A, 0071A, 0072A, 0073A
      • Moderna: 0011A, 0012A, 0013A, 064A
      • Janssen: 0031A, 0034A
    • The second code must be M0201 (COVID-19 vaccine home administration)
    • For a definition of what constitutes in-home administration, see this CMS fact sheet (PDF - 138 KB).

No. For the HRSA COVID-19 Uninsured Program, facility reimbursement based on IPPS does not include the 20% increase to the DRG weight for COVID-19 diagnoses U07.1 and B97.29 authorized by Section 3710 of the CARES Act.

Yes. The program reimburses providers for COVID-19 testing, treatment, or vaccine administration fees for uninsured individuals; therefore, any money collected from the individual must be returned to the individual if the provider received funding for that patient through this program.

This requirement is included in the Terms and Conditions that the provider signs in order to enroll in the program.

You can download an 835 file, as well as download the Electronic Provider Remittance Advice (PDF version of the 835 file) for the HRSA COVID-19 Uninsured Program, by accessing Optum Pay™ with your Optum ID. On the Optum Pay website you can access your remittance information on the View Payments tab. You can find that tab by following this path:

• Log in to Optum Pay.
• Select the Tax Identification Number (TIN) associated with the claims you are looking to reconcile.
• Select View Payments.

You will need to access the 835 file in order to upload it into your practice management system. This will allow you to reconcile your claims as you would if you had received the 835 file via your clearinghouse. Please allow for appropriate processing time. As part of the HRSA COVID-19 Uninsured Program, the 835 file will not be electronically routed to you from your clearinghouse.

Multiple individuals in an organization can have an Optum ID, but only one person per TIN can serve as the administrator. If the portal indicates that the TIN you entered already has an administrator and you cannot identify that individual, please call 866-569-3522. We will work with your organization to identify the correct TIN administrator and reassign this role after appropriate security requirements are met.

As part of the HRSA COVID-19 Uninsured Program, the 835 file will not be electronically routed to you from your clearinghouse.