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

Health care entities who have conducted COVID-19 testing of uninsured individuals, provided treatment to uninsured individuals with a COVID-19 primary diagnosis, or administered an FDA-authorized or licensed COVID-19 vaccine to uninsured individuals on or after February 4, 2020, can request claims reimbursement through the program electronically and are reimbursed generally at Medicare rates, subject to available funding.

Yes. Unaccompanied children are considered uninsured individuals for the purposes of claims reimbursement under the HRSA COVID-19 Uninsured Program. Health care providers who have conducted COVID-19 testing; provided treatment for a COVID-19 primary diagnosis; or administered an FDA-authorized or licensed COVID-19 vaccine to unaccompanied children may submit claims for reimbursement if the provider attests to the Terms and Conditions (PDF - 123 KB) of the Uninsured Program.

For claims for COVID-19 testing and testing-related items and services, treatment of positive cases of COVID-19, and vaccine administration claims, a patient is considered uninsured if the patient did not have any health care coverage at the time services were rendered.

Health care providers are not required to confirm immigration status prior to submitting claims for reimbursement. Health care providers who have conducted COVID-19 testing of any uninsured individual, provided treatment to any uninsured individual with a COVID-19 primary diagnosis, or administered an FDA-authorized or licensed COVID-19 vaccine to any uninsured individual, including providing these services to unaccompanied children, for dates of service or admittance on or after February 4, 2020, may be eligible for claims reimbursement through the program as long as the service(s) provided meet the coverage and billing requirements established as part of the program.

The American Rescue Plan Act of 2021 (ARPA, P.L. 117-2) included a requirement that most Medicaid limited-benefit plans cover COVID-19 vaccine administration, effective March 11, 2021.  ARPA also required Medicaid limited COVID-19 testing plans to cover COVID-19 treatment.  For more information, see the CMCS Informational Bulletin (PDF).

The HRSA COVID-19 Uninsured Program reimburses eligible claims for COVID-19 testing, treatment, and vaccination for individuals with limited Medicaid benefits if the Medicaid plan does not cover these services. HRSA's contractor, UnitedHealth Group (UHG), checks if the patient on the claim has other health care coverage using standard eligibility transactions. Currently, if UHG finds the patient has Medicaid coverage with limited benefits, the program reimburses the claim if otherwise eligible, but conducts coordination of benefits after payment to verify the patient’s Medicaid plan did not cover the COVID-19 services on the claim. If the Medicaid plan covered services that the Uninsured Program reimbursed, the program would offset the overpayment against any pending claims from the provider; if an offset is not possible, the provider must return the overpayment.

Providers must verify and attest that to the best of the provider's knowledge at the time of claim submission, the patient was uninsured at the time the services were provided. For claims for COVID-19 testing and testing-related items and services, treatment of positive cases of COVID-19, and/or vaccine administration, this means that the patient did not have any health care coverage. Providers may submit a claim for uninsured individuals before Medicaid eligibility determination is complete. However, if the provider learns that the individual is retroactively enrolled in Medicaid as of the date of service, the provider must return the payment to HRSA.

The optional COVID-19 testing eligibility group, added by section 6004(a)(3) of the FFCRA at section 1902(a)(10)(A)(ii)(XXIII) of the Act, is similar to other optional eligibility groups under which states can elect to furnish a targeted set of benefits to eligible individuals. To reimburse providers for the covered services, a state must elect to adopt this group under its state plan.

States that do so can then reimburse providers enrolled in their Medicaid program for in vitro diagnostic testing and other COVID-19 testing-related services furnished to individuals whom the agency has determined are eligible under the new group. For more information on the eligibility requirements for the optional COVID-19 testing eligibility group, covered benefits, the availability of hospital presumptive eligibility for the new group, and the availability of 100 percent Federal Medical Assistance Percentage (FMAP) for the testing services provided to individuals eligible under the optional COVID-19 testing eligibility group, see these FAQs (PDF). For more information on strategies to assist states in operationalizing this group, see this guidance (PDF).

HRSA is administering a separate program, referred to as the COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured Program (HRSA COVID-19 Uninsured Program). This program provides reimbursement directly to eligible providers and has two components:

1. Reimbursement for COVID-19 testing services. This component, which reimburses providers for conducting COVID-19 testing for uninsured individuals, was authorized and initially funded via the FFCRA and the Paycheck Protection Program and Health Care Enhancement Act (PPPHCA). The FFCRA and the PPPHCA each appropriated $1 billion (for a total of $2 billion) for this purpose. With the initial $2 billion fully disbursed, the HRSA COVID-19 Uninsured Program currently reimburses providers for COVID-19 testing claims using funding allocated through the American Rescue Plan Act (ARPA) and a portion of the funding that comprises the Provider Relief Fund.
2. Reimbursement for COVID-19 treatment services and vaccine administration. This component is authorized via the CARES Act, which provides $100 billion in relief funds for hospitals and other health care providers, including those on the front lines of the COVID-19 response. The PPPHCEA appropriated an additional $75 billion; and the Coronavirus Response and Relief Supplemental Appropriations Act (CRRSA) appropriated an additional $3 billion in relief funds. A portion of the Provider Relief Fund supports health care-related expenses attributable to the treatment of uninsured individuals with COVID-19 and COVID-19 vaccine administration to the uninsured in addition to COVID-19 testing of the uninsured, as explained above.

To access these funds, health care providers must enroll in the program as a provider participant. Once they have done so, they can submit claims for direct reimbursement for COVID-19 testing and treatment services furnished to uninsured individuals on or after February 4, 2020, and for COVID-19 vaccine administration fees for the uninsured.

Health care providers who have conducted COVID-19 testing of uninsured individuals, treated uninsured individuals with a COVID-19 primary diagnosis, or administered COVID-19 vaccine to uninsured individuals on or after February 4, 2020, may be eligible for claims reimbursement through the program as long as the service(s) provided meet the coverage and billing requirements established as part of the program.

Under the COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured Program (Uninsured Program), health centers are eligible to seek reimbursement for conducting COVID-19 testing, providing treatment for uninsured individuals with a COVID-19 diagnosis, or for administering an FDA-authorized or approved COVID-19 vaccine to uninsured individuals. Health Center Program requirements include an obligation under section 330(k)(3)(F) for health centers to make “every reasonable effort to collect appropriate reimbursement for its costs in providing health services” from potential payers (see also [Chapter 16: Billings and Collection, Health Center Compliance Manual]). Health Centers are also required to provide financial and budget information relating to nongrant fund program income. These requirements do not impact a health center’s eligibility to submit reimbursement claims to the Uninsured Program.

If a health center also receives Ryan White HIV/AIDS Program grant funds under title XXVI of the Public Health Service (PHS) Act, please refer to the HRSA HIV/AIDS Bureau website for further information. In addition, please continue to ensure that you are allocating and tracking appropriate grant funds.

In accordance with the requirements of the Uninsured Program, in order to seek reimbursement, a health center must agree to the following as attested at registration:

• You will accept defined program reimbursement as payment in full.
• You agree not to balance bill the patient.

Therefore, if a health center accepts reimbursement from the Uninsured Program, it may not balance bill/charge the patient.

For questions about Health Center Program billing and collections, sliding fee discount program, and other requirements please contact Health Center Program Support. More information about the Health Center Program is also available, including FAQs related to COVID-19 and health centers.

Ryan White HIV/AIDS Program (RWHAP) recipients are prohibited from submitting claims for reimbursement for services provided to RWHAP clients to the COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured Program.

The FY 2020 CARES Act funding provided to Ryan White HIV/AIDS Program (RWHAP) recipients through RWHAP Part A should be used for preventing, preparing for, and responding to COVID-19, as needs evolve for clients of RWHAP recipients. The COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured Program—authorized by the Families First Coronavirus Response Act, Paycheck Protection Program and Health Care Enhancement Act, CARES Act, Coronavirus Response and Relief Supplemental Appropriations Act, and American Rescue Plan Act of 2021 and administered by HRSA—is not a state compensation program, an insurance policy, a federal or state health benefits program, or an entity that provides health services on a prepaid basis. As such, it does not trigger the payer of last resort provision codified in the RWHAP legislation. RWHAP providers should use their COVID-19 CARES Act funding specifically authorized for the RWHAP patient population, and are prohibited from accessing the Provider Relief Fund for these same services. For those RWHAP providers that provide services to a broad range of patients, claims may be submitted for services provided to non-RWHAP eligible clients.

No. Individuals who are I/T/U beneficiaries are not considered uninsured individuals for the CARES Act Provider Relief Fund.  I/T/Us may submit claims for reimbursement for testing, treatment, and/or vaccine administration they provide to non-I/T/U beneficiaries who otherwise meet the definition of "uninsured individuals" in the Terms and Conditions (Attestation (PDF - 123 KB)) of the Uninsured Program.

The HRSA COVID-19 Uninsured Program provides claims reimbursement to health care providers for COVID-19 testing, treatment, or vaccine administration for uninsured individuals who did not have any health care coverage at the time services were rendered. In contrast, the HRSA COVID-19 Coverage Assistance Fund reimburses providers for COVID-19 vaccine administration provided to individuals who have health insurance but are underinsured in terms of COVID-19 vaccination coverage, meaning their health plan either does not include COVID-19 vaccination as a covered benefit or covers COVID-19 vaccination but with cost-sharing. Both programs work toward the goal of supporting providers in increasing access to COVID-19 vaccination and other COVID-19 health services for individuals living in the United States. However, because claims for underinsured individuals require additional coordination with insurers, the programs operate separate portals for providers serving each patient population. Find more information about the HRSA COVID-19 Coverage Assistance.

If a claim was submitted to the HRSA COVID-19 Uninsured Program for a patient who was actually insured, the provider should receive a notice that the claim was not eligible for reimbursement. If the claim was for COVID-19 vaccine administration and the patient’s health plan either did not include COVID-19 vaccination as a covered benefit or covered COVID-19 vaccination but with cost-sharing, then the provider could instead submit the claim to the HRSA COVID-19 Coverage Assistance Fund. Prior to submitting a claim to the Coverage Assistance Fund, the provider should first submit the claim to the individual’s health insurance plan for payment. Only those COVID-19 vaccine administration claims denied or not fully paid by a patient’s health insurance plan, including those insurance plans with patient co-pays for vaccine administration, deductibles for vaccine administration, or co-insurance related to COVID-19 vaccination, are eligible for reimbursement by the HRSA COVID-19 Coverage Assistance Fund.

For dates of service or admittance on or after February 4, 2020 (aligning with Medicare coverage of COVID-19 services), reimbursement is made for qualifying testing for COVID-19, treatment services with a primary COVID-19 diagnosis, or for qualifying COVID-19 vaccine administration, as determined by HRSA (subject to adjustment as may be necessary), including the following:

• Specimen collection, diagnostic and antibody testing.
• Testing-related visits including in the following settings: office, urgent care or emergency room or telehealth.
• Treatment, including office visit (including telehealth), urgent care, emergency room, inpatient, outpatient/observation, skilled nursing facility, long-term acute care (LTAC), acute inpatient rehab, home health, DME (e.g., oxygen, ventilator), emergency ambulance transportation, non-emergent patient transfers via ambulance, and FDA-licensed, authorized, or approved treatments as they become available for COVID-19 treatment.
• Dispensing fees for FDA-licensed or authorized outpatient antiviral drugs for treatment of COVID-19.
• Administration fees related to FDA-authorized or licensed vaccines.

Claims are subject to Medicare timely filing requirements.

Independent labs do not always know the reason for testing when ordered by another provider and they are dependent on the diagnosis information indicated by the provider. Therefore, HRSA reimburses for specific COVID-19 diagnostic testing services (individual procedure codes) for any diagnosis only when performed by independent labs.

Yes, a provider can submit claims for testing furnished to an uninsured individual that is performed by a laboratory with which the provider has a client bill arrangement. In these cases, if a provider receives a reimbursement payment, the provider would be responsible for paying the lab as they normally do under these arrangements. Per the terms and conditions, the provider may not balance bill the uninsured individual.

Services not covered by traditional Medicare will also not be covered under this program. In addition, the following services are ineligible for reimbursement:

• Any treatment without a COVID-19 primary diagnosis, except for pregnancy when the COVID-19 code may be listed as secondary.
• Hospice services.
• Outpatient prescription drugs, except for the dispensing fee for FDA-licensed or authorized outpatient antiviral drugs for treatment of COVID-19.

All claims submitted must be complete and final.

Yes, for the HRSA COVID-19 Uninsured Program, claims must be submitted within 365 calendar days from date of service or admittance, and are subject to available funding.

For the HRSA COVID-19 Uninsured Program, claims for diagnostic testing are eligible for reimbursement if one of the following diagnoses codes is included in any position on the claim:

• Z03.818 - Encounter for observation for suspected exposure to other biological agents ruled out
• Z11.52 - Encounter for screening for COVID-19
• Z11.59 - Encounter for screening for other viral diseases
• Z20.822 - Contact with and (suspected) exposure to COVID-19
• Z20.828 - Contact with and (suspected) exposure to other viral communicable
• Z86.16 - Personal history of COVID-19

Claims for diagnostic testing-related visits are eligible for reimbursement if the place of service is an office visit, telehealth visit, urgent care or emergency room AND one of the following diagnoses codes is included in any position on the claim:

• Z03.818 - Encounter for observation for suspected exposure to other biological agents ruled out
• Z11.52 - Encounter for screening for COVID-19
• Z11.59 - Encounter for screening for other viral diseases
• Z20.822 - Contact with and (suspected) exposure to COVID-19
• Z20.828 - Contact with and (suspected) exposure to other viral communicable
• Z86.16 - Personal history of COVID-19

While U0001, U0002, U0003, U0004, G2023, G2024 and 87635 are COVID-19 specific procedure codes, one of the Z codes above needs to be included on the claim from hospitals and physicians in order to be eligible for reimbursement for testing as part of the HRSA COVID-19 Uninsured Program.

For independent labs, single line item claims for the following procedure codes with any diagnosis are also eligible for reimbursement:

• COVID-19 tests: U0001, U0002, U0003, U0004, 87635, 87426, 87428, 87636, 87637, 87811, 0225U, 0226U, 0240U, 0241U
• Antibody tests: 86318, 86328, 86769
• Specimen collection: G2023, G2024

Claim reimbursement eligibility for diagnostic testing services performed by independent labs is different than claim reimbursement eligibility for such services performed by hospitals (including hospital labs) or physicians. This is because independent labs do not always know the reason for testing when ordered by another provider and they are dependent on the diagnosis information indicated by the provider. Therefore, HRSA reimburses for specific COVID-19 diagnostic testing services (individual procedure codes) for any diagnosis only when performed by independent labs.

For the HRSA COVID-19 Uninsured Program, COVID-19 testing are eligible for reimbursement if one of the following diagnoses codes is included in any position on the claim:

• Z03.818 - Encounter for observation for suspected exposure to other biological agents ruled out (possible exposure to COVID-19)
• Z11.59 - Encounter for screening for other viral diseases (asymptomatic)
• Z20.828 - Contact with and (suspected) exposure to other viral communicable (confirmed exposure to COVID-19)
• Z11.52 - Encounter for screening for COVID-19 (asymptomatic)
• Z20.822 - Contact with and (suspected) exposure to COVID-19
• Z86.16 - Personal history of COVID-19

Related treatment visits and services are not eligible for reimbursement given the primary reason for treatment is not COVID-19.

The test and visit are eligible for reimbursement if they otherwise meet the criteria defined by the program.

For the HRSA COVID-19 Uninsured Program, claims for diagnostic testing are eligible for reimbursement if one of the following diagnoses codes is included in any position on the claim:

• Z03.818 - Encounter for observation for suspected exposure to other biological agents ruled out (possible exposure to COVID-19)
• Z11.59 - Encounter for screening for other viral diseases (asymptomatic)
• Z20.828 - Contact with and (suspected) exposure to other viral communicable (confirmed exposure to COVID-19)
• Z11.52 - Encounter for screening for COVID-19 (asymptomatic)
• Z20.822 - Contact with and (suspected) exposure to COVID-19
• Z86.16 - Personal history of COVID-19

Claims for diagnostic testing-related visits are eligible for reimbursement if the place of service is an office visit, telehealth visit, urgent care or emergency room AND one of the following diagnoses codes is included in any position on the claim:

• Z03.818 - Encounter for observation for suspected exposure to other biological agents ruled out (possible exposure to COVID-19)
• Z11.59 - Encounter for screening for other viral diseases (asymptomatic)
• Z20.828 - Contact with and (suspected) exposure to other viral communicable (confirmed exposure to COVID-19)
• Z11.52 - Encounter for screening for COVID-19 (asymptomatic)
• Z20.822 - Contact with and (suspected) exposure to COVID-19
• Z86.16 - Personal history of COVID-19

While U0001, U0002, U0003, U0004, G2023, G2024 and 87635 are COVID-19 specific procedure codes, one of the Z codes above needs to be included on the claim from hospitals and physicians in order to be eligible for reimbursement for testing as part of the HRSA COVID-19 Uninsured Program.

Yes. For diagnostic testing and testing-related services, claims submitted for testing-related visits rendered in an office, urgent care or emergency room, or via telehealth are eligible for reimbursement if they include one of the following diagnosis codes:

• Z03.818 - Encounter for observation for suspected exposure to other biological agents ruled out (possible exposure to COVID-19)
• Z20.828 - Contact with and (suspected) exposure to other viral communicable (confirmed exposure to COVID-19)
• Z11.59 - Encounter for screening for other viral diseases (asymptomatic)
• Z11.52 - Encounter for screening for COVID-19 (asymptomatic)
• Z20.822 - Contact with and (suspected) exposure to COVID-19
• Z86.16 - Personal history of COVID-19

For the HRSA COVID-19 Uninsured Program, eligible treatment claims are determined as follows:

• Treatment claims for services or discharges prior to April 1, 2020, are eligible for reimbursement if the primary diagnosis is B97.29 OR if the primary diagnosis is pregnancy O98.5- and the secondary diagnosis is B97.29.
• Treatment claims for services or discharges on or after April 1, 2020, are eligible for reimbursement if the primary diagnosis is U07.1 OR if the primary diagnosis is pregnancy O98.5- and the secondary diagnosis is U07.1.

For the HRSA COVID-19 Uninsured Program, the criteria for treatment to be eligible for reimbursement is as follows:

• Treatment claims for services or discharges prior to April 1, 2020, are eligible for reimbursement if the primary diagnosis is B97.29 OR if the primary diagnosis is pregnancy O98.5- and the secondary diagnosis is B97.29.
• Treatment claims for services or discharges on or after April 1, 2020, are eligible for reimbursement if the primary diagnosis is U07.1 OR if the primary diagnosis is pregnancy O98.5- and the secondary diagnosis is U07.1.

To address the usage of B97.29 as a primary diagnosis, we refer providers to recent guidance released by CMS: (see CR 11764 (PDF - 183 KB)). This guidance explicitly allows for B97.29 to be included in any position on the claim.

The goal of the program is to provide consistent eligibility for reimbursement of COVID-19 treatment before and after April 1, 2020, when the U07.1 diagnosis code became effective. Prior to the effective date of the U07.1 code we rely on the B97.29 code to identify claims where COVID-19 is the primary reason for treatment.

HRSA is not providing coding guidance to providers. The program guidance is intended to define what services are eligible for reimbursement under the program.

For the HRSA COVID-19 Uninsured Program, eligible treatment claims are determined as follows:

• Treatment claims for services or discharges prior to April 1, 2020, are eligible for reimbursement if the primary diagnosis is B97.29 OR if the primary diagnosis is pregnancy O98.5- and the secondary diagnosis is B97.29.
• Treatment claims for services or discharges on or after April 1, 2020, are eligible for reimbursement if the primary diagnosis is U07.1 OR if the primary diagnosis is pregnancy O98.5- and the secondary diagnosis is U07.1.

Yes, but not until the grace period is exhausted and coverage is terminated.  Qualified health plans are permitted pursuant to 45 CFR §156.270(d)(1) to pend a claim (i.e., withhold payment) during months 2 and 3 of the grace period applicable for enrollees receiving advance payments of the premium tax credit.  However, during the grace period, the coverage is still in force, and the plan may be required to pay the claims if the enrollee pays all outstanding amounts before the grace period is exhausted.  Until the plan is relieved of the potential obligation to pay the claims (i.e., upon termination retroactive to the end of month 1 of the grace period), the provider may not submit the claim to the HRSA COVID-19 Uninsured Program.  Once the grace period is exhausted and coverage is terminated retroactively to the end of month 1 of the grace period, the individual would not have health insurance coverage for months 2 and 3 of the grace period for purposes of the Provider Relief Fund, and the provider could submit claims for reimbursement to the HRSA COVID-19 Uninsured Program. The same approach would apply if the service was administered while an enrollee was in a state grace period but whose coverage was ultimately terminated retroactively for non-payment, leaving the enrollee uninsured at the time of the service.

This program is available to reimburse providers for COVID-19 testing and testing-related visits for uninsured individuals, treatment for uninsured individuals with a COVID-19 diagnosis, and COVID-19 vaccination administration fees. Providers can familiarize themselves with this process at www.hrsa.gov/coviduninsuredclaim, and learn more and file claims at https://coviduninsuredclaim.linkhealth.com. Providers should submit the claim for the uninsured individual to the HRSA COVID-19 Uninsured Program only if and after the grace period is exhausted and coverage has been terminated, or if the issuer coverage for the claim is reversed. Pursuant to 45 CFR 156.270(d)(3), Exchange issuers are required to notify providers of the possibility for denied claims when an enrollee is in the second and third months of the grace period where the enrollee is receiving APTC.