COVid-19 testing clinical policy update

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Apple Health (Medicaid) Provider Alert

Attention providers:

This alert replaces the COVID-19 testing clinical policy update alert sent on September 28, 2021. The Health Care Authority has increased the total limit for PCR and antigen tests.

What changed? 

Effective for claims with dates of service on and after October 1, 2021, HCA updated the COVID-19 testing clinical policy as follows:

  • Added the limit of 12 total PCR and antigen tests, per client, per month. For additional tests, providers must submit a limitation extension request to HCA.
  • Added over-the-counter (OTC) COVID testing and billing information for pharmacies.
    • Pharmacies may bill for OTC tests prescribed by a provider with prescriptive authority, using a standing order, or when a pharmacist has a collaborative practice agreement that allows for COVID testing.
    • To bill for the OTC COVID tests, pharmacies must follow the NCPDP standard and use the national drug code (NDC) or universal product code (UPC) found on the package.
    • Pharmacies may not bill for test administration of an OTC COVID test. These tests should be used by the patient in the home setting.