Dear Valued CPhA Member,
On April 27, 2020, the Centers for Medicare and Medicaid Services’ (CMS) Health Resources and Services Administration (HRSA) division created a website that will allow health care providers (including pharmacies) who provide Medicare COVID-19 testing and treatment services
to the uninsured
to submit claims for reimbursement. This program is being administered by
Providers will be able to submit electronic claims for reimbursement at Medicare rates for COVID-19 testing and treatment on or after February 4, 2020, subject to available funding from the Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, and Economic Security (CARES) Act. Participation is subject to the following:
You have checked for health care coverage eligibility and confirmed that the patient is uninsured. You have verified that the patient does
have coverage such as individual, employer-sponsored, Medicare or Medicaid coverage, and no other payer will reimburse you for COVID-19 testing and/or care for that patient.
You will accept defined program reimbursement as payment
You agree not to balance bill the patient.
You agree to program terms and conditions and may be subject to post-reimbursement audit review.
Providers who choose to participate in this program must sign up to participate at
. You’ll be directed to
create an Optum ID
if you don’t already have one. If you have an Optum ID then you can immediately access the program portal.
Once you have a valid Optum ID, you must validate your taxpayer identification number (TIN) which will take 1-2 business days to process. Then you must set up your
Automated Clearing House (ACH) for electronic payment. This will take roughly 7-10 business days to process. Optum Pay will require the following:
- TIN or EIN
- Business name
- Provider type
- Name of Administrator(s) (One administrator per TIN)
- Contact information
- Bank name and contact information
- Financial institution account information
- Voided check or bank letter
- Signed and dated W-9
After setting up your Optum Pay, then you’ll need to provide your provider roster. This roster will only provide verification for participation in the HRSA COVID-19 Uninsured Program and will NOT constitute a network contract nor will you be credentialed. This step will take 1-3 business days to process.
Beginning May 6, 2020, you’ll need to complete a patient attestation, verifying that the patient is uninsured, and upload your patient roster with the following information:
- First and last name
- Date of birth
- *SSN and state of residence; if not available, enter state identification / driver's license
- Date of service for physician, lab or facility outpatient services.
- Date of admission and date of discharge for facility inpatient services.
- Address (optional)
- Middle initial (optional)
- Patient account number (optional)
Patient information may be uploaded as a batch or one at a time. After uploading, you’ll receive a temporary member ID for each patient. This ID will be displayed in the program portal in 1-3 business days after submission. Temporary member ID is valid for 30 days from date of service or date of discharge for facility inpatient services. The portal will provide updates on all processing of steps.
Claims for reimbursement will start on May 6, 2020. The provider must submit the claim electronically for professional and facility services (ANSI X12 837) via and an 837 EDI transaction set. These claims are submitted outside of the program portal and is subject to available funding. The provider will need to submit the payer ID 95964, the payer name “COVID19 HRSA Uninsured Testing and Treatment Fund”, and the temporary ID number for each patient. Additionally, you’ll need to submit the appropriate
. Payment for these services are expected to be received in 7-10 business days via direct deposit to the provider’s account. The earliest payment that providers will receive will begin on May 18, 2020.
Reimbursement will be made for qualifying testing for COVID-19 and treatment services with a primary COVID-19 diagnosis, including the following:
- Specimen collection, diagnostic and antibody testing.
- Testing-related visits including in the following settings: office, urgent care or emergency room or via telehealth.
- Treatment, including office visit (including via telehealth), emergency room, inpatient, outpatient/observation, skilled nursing facility, long-term acute care (LTAC), acute inpatient rehab, home health, DME (e.g., oxygen, ventilator), emergency ground ambulance transportation, non-emergent patient transfers via ground ambulance, and FDA approved drugs as they become available for COVID-19 treatment and administered as part of an inpatient stay.
- FDA-approved vaccine, when available.
- For inpatient claims, date of admittance must be on or after February 4, 2020.
It should be noted that services that are not covered for traditional Medicare will also not be covered by this programs. Additionally, any treatment without a valid COVID-19 diagnosis (except for pregnancy when the COVID-19 code can be listed as a secondary), hospice services and outpatient prescription drugs will be
for reimbursement under this program.
Lastly, claims for reimbursement will be priced as described below for eligible services.
- Reimbursement will be based on current year Medicare fee schedule rates except where otherwise noted.
- Reimbursement will be based on incurred date of service.
- Publication of new codes and updates to existing codes will be made in accordance with CMS.
- For any new codes where a CMS published rate does not exist, claims will be held until CMS publishes corresponding reimbursement information.
It should be noted that CPhA continues to advocate to the Governor’s office to authorize pharmacists to perform COVID-19 testing. This information is being presented to our members in anticipation of such authorization.