Healthcare Providers

Billing & Claims

During this challenging and unprecedented event, CareFirst wants to keep you informed of the benefit updates we are making to ensure our members, your patients, have access to the care they need. Please note that general guidance appears first on this page, followed by Medicare Advantage-specific guidance at the bottom.

As new codes are released, please allow 30 days before billing the new codes to allow for us to have them configured in our systems appropriately.

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Billing and Submitting Claims for COVID-19 Vaccines

CareFirst members will pay $0 for any authorized COVID-19 vaccine. Providers will be reimbursed by CareFirst for administration of a vaccine. The vaccine is paid for by the federal government. Providers should not submit claims for the cost of the vaccine.

Effective for dates of service on and after June 8, 2021, CareFirst is increasing fees for in-home vaccinations in alignment with the CMS. Professional providers may bill M0201 in addition to existing vaccine administration codes for COVID-19 vaccines given in the home. This increase is designed to promote vaccine accessibility in vulnerable and hard-to-reach populations.

Medical providers should submit claims for vaccine administration using the appropriate codes below. Dental providers should refer to the information under the Dental tab for the appropriate CDT and CPT codes.

Adults

Manufacturer	First Dose Administration CPT	Second Dose Administration CPT	Third Dose Administration CPT	Booster Administration CPT
Pfizer BioNTech	0001A	0002A	0003A (effective 8/12/21)	0004A (effective 10/20/21)
Moderna Vaccine/Spikevax COVID-19 Vaccine (Spikevax)	0011A	0012A	0013A (effective 8/12/21)	0064A (effective 10/20/21)
Janssen (Johnson & Johnson)	0031A	n/a	n/a	0034A (effective 10/20/21)
Novavax	0041A	0042A	n/a	n/a
Pfizer	0051A	0052A	0053A	0054A
Moderna	n/a	n/a	n/a	0094A

Pediatrics

Manufacturer	First Dose Administration CPT	Second Dose Administration CPT	Third Dose Administration CPT	Booster Administration CPT	Notes
Pfizer BioNTech	0071A (effective 10/29/21)	0072A (effective 10/29/21)	0073A (effective 1/1/22)	0074A (effective 5/17/22)	5 months through 11 years of age
Pfizer BioNTech	0081A (effective 06/17/22)	0082A (effective 6/17/22)	0083A (effective 6/17/22)	n/a	6 months through 4 years of age
Moderna	0111A (effective 06/17/22)	0112A (effective 6/17/22)	0113A (effective 6/17/22)	n/a	6 months through 5 years of age
Moderna	0091A (effective 06/17/22)	0092A (effective 6/17/22)	0093A (effective 6/17/22)	n/a	6 months through 11 years of age

COVID-19 Vaccine Administration Fees for Medicare Advantage–For dates of service prior to January 1, 2022, providers who administer a COVID-19 vaccine for a Medicare Advantage member should bill Medicare directly for the administration fee. Beginning January 1, 2022, providers should bill CareFirst for vaccine administration fees for Medicare Advantage members.

Billing and Submitting Commercial Claims for Coronavirus Treatment

As of September 1, 2021, CareFirst is no longer waiving cost sharing (copays, coinsurance and deductibles) for in-network or out-of-network visits to a provider’s office, lab fees or treatments related to COVID-19 treatment. This does not apply to monoclonal antibody treatment (see codes in chart below).

Effective for dates of service on and after September 1, providers may collect copays for services related to COVID-19 treatment. This change applies to commercial members. Effective January 1, 2022, this change will also apply to Medicare Advantage members.

Billing for Monoclonal Antibody Infusion

Providers will be reimbursed by CareFirst for administration of the drug. The drug is paid for by the federal government. Providers should not submit claims for the cost of the drug.

Maryland providers: please see the recent Maryland Department of Health expanded authorization of REGEN-COV and fact sheet.

COVID-19 Treatment	Date of Service	Administration Code(s)
Monoclonal Antibody Infusion code (Covered for all qualified in-network providers. Prior authorization is not required).	On or after November 21, 2020	M0243 (casirivimab and imdevimab)
	On or after November 21, 2020	Q0243 (Injection, casirivimab and imdevimab, 2400 mg)
	On or after February 9, 2021	M0245 (intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring)
	On or after February 9, 2021	Q0245 (injection, bamlanivimab and etesevimab, 2100 mg)
	On or after May 6, 2021	M0244 (Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring in the home or residence)
	On or after May 6, 2021	M0246 (Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring in the home or residence)
	On or after May 26, 2021	Q0247 (Injection, sotrovimab, 500 mg)
	On or after May 26, 2021	M0247 (Intravenous infusion, sotrovimab, includes infusion and post administration monitoring)
	On or after May 26, 2021	M0248 (Intravenous infusion, sotrovimab, includes infusion and post administration monitoring in the home or residence)
	On or after June 3, 2021	Q0244 (Injection, casirivimab and imdevimab, 1200 mg)
	On or after June 24, 2021	M0249 (Intravenous infusion, tocilizumab) includes infusion and post administration monitoring, first dose
	On or after June 24, 2021	M0250 (Intravenous infusion, tocilizumab) includes infusion and post administration monitoring, second dose
	On or after July 30, 2021	M0240 (Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring, subsequent repeat doses)
	On or after July 30, 2021	M0241 (Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring in the home or residence, subsequent repeat doses)
	On or after July 30, 2021	Q0240 (Injection, casirivimab and imdevimab, 600 mg)
	On or after November 10, 2020 through April 16, 2021 (when the FDA revoked emergency use authorization)	HCPCS codes: M0239 (bamlanivimab-xxxx)

Remdesivir in the Outpatient Setting

In view of supply shortages for current COVID-19 therapeutic treatments, effective January 12, 2022, CareFirst is covering a three-day hospital outpatient course of VEKLURY (Remdesivir) infusion treatment.

No prior authorization is required.
Normal cost sharing and benefit limitations apply.
CMS has created HCPS code J0248 for Remdesivir when delivered in an outpatient setting.

This coverage applies to all CareFirst members: Commercial, Federal Employee Program, Medicaid, Dual Eligible Special Needs and Medicare Advantage.

Providers in other outpatient settings who wish to offer Remdesivir should reach out to their Provider Contracting Representative to discuss further.

Read the NIH COVID-19 Treatment Guidelines Panel’s Statement on Therapies for High-Risk, Non-Hospitalized Patients with Mild to Moderate COVID-19.

Submitting Commercial Claims for Office Visits, Urgent Care or ER Visits

Submit claims for office visits, urgent care, or ER visits for the purpose of diagnosing or ordering testing for COVID-19 using ICD-10 primary diagnosis code of Z20.828 regardless of the place of service. Use the following ICD-10 reporting codes for billing COVID-19 treatment:

Treatment of coronavirus- use code U07.1 as primary diagnosis code
Treatment of comorbidity symptoms should be submitted with the appropriate diagnosis code

For cases where there was a concern about a possible exposure to COVID-19, but was ruled out after evaluation, submit claims using ICD-10 primary diagnosis code of Z03.818.

Claims for asymptomatic individuals who are being screened for COVID-19, have no known exposure to the virus, and the test results are either unknown or negative, should be submitted using ICD-10 primary diagnosis code Z11.59.

For more information on claims reporting view the CDC’s ICD-10-CM Official Coding and Reporting Guidelines.

Submitting Claims for Medically Necessary COVID-19 Testing

Effective May 12, 2023, claims for COVID-19 testing will be processed and paid according to the member’s contract.

The information below is for historical purposes and was effective until May 12, 2023.

CareFirst covers, with no cost share to the member (including our members enrolled in high deductible health plans), the appropriate medically necessary diagnostic testing for COVID-19. Tests must be FDA authorized or approved and ordered by an authorized healthcare professional. The chart below provides information for submitting claims for our commercial members.

For information on how we cover surveillance testing, please review this FAQ

COVID-19 Test	Date of Service	Code(s)
Standard Diagnostic COVID-19 Testing	On or after February 4, 2020	HCPCS code U0002
Standard Diagnostic COVID-19 Testing	On or after March 13, 2020	CPT 87635
Standard Diagnostic COVID-19 Testing Combined with Flu A and B	On or after October 6, 2020	HCPCS code 0240U CPT code 87636
Standard Diagnostic COVID-19 Testing Combined with Flu A and B and RSV	On or after October 6, 2020	HCPCS code 0241U CPT code 87637
Serology/Antibody Testing Antibody tests must be on the EUA list, be ordered by the patient’s provider, be medically necessary and have a high likelihood of impacting clinical decision making.	On or after April 11, 2020	CPT codes 86328 or 86769
Detection of the presence and temporal evolution of the adaptive immune response after COVID-19 infection	On or after September 8, 2020	86413
Rapid Antigen Testing Practices must have a Clinical Laboratory improvement Amendments Certificate of Waiver to conduct rapid antigen tests when the test is administered.	On or after June 25, 2020	CPT code 87426
Direct Visual Antigen	On or after August 18, 2020	CPT code 87811
Proprietary Lab Analysis Diagnostic Testing for Detecting COVID-19	On or after October 6, 2020	HCPCS code 0225U
Neutralizing antibody	On or after August 10, 2020	86408-screen 86409-titer
Multiplex viral pathogen panel using immunoassay technique for SARS-CoV-2 testing along with influenza A and influenza B	On or after November 10, 2020	87428

Billing for Home Births

Home birth services are covered for our commercial members when the member has maternity coverage. When billing for home deliveries, use place of service code 12 and refer to the provider guidelines in the Global Maternity Care Medical Policy (4.0.1.66A) for procedure coding guidance.

Lab Services for Commercial Members

Effective May 12, 2023, for utilization of in-network laboratories, members will have to follow the requirements of their contract. BlueChoice members are required to utilize LabCorp.

The information below is for historical purposes prior to May 12, 2023.

For the duration of this public health emergency, CareFirst has expanded the scope of our contracted lab partners to support access to testing as it becomes available. As part of this expansion, providers and BlueChoice members are not limited to using LabCorp for COVID-19 testing. COVID-19 tests may be sent to any lab contracted with CareFirst authorized to perform the testing, including hospital-based labs. We also cover CPT Proprietary Laboratory Analysis codes 0224U and 0223U.

Billing and Submitting Medicare Advantage Claims for Coronavirus Treatment

Effective May 12, 2023, Medicare Advantage member’s claims are processed in accordance with their contract. Cost share waiver no longer applies.

The information below is for historical purposes prior to May 12, 2023.

CareFirst is waiving cost sharing (copays, coinsurance and deductibles) for in-network or out-of-network visits to a provider’s office for treatments related to COVID-19.

Submit claims (Professional/Facility) with U07.1 (COVID-19) or J12.82 (Pneumonia due to coronavirus disease) as the primary diagnosis.

Cost share will also be waived when certain diagnosis codes for obstetrics, sepsis, or transplant complications are listed as primary with U07.1 or J12.82 as secondary.

Submitting Medicare Advantage Claims for Office Visits, Urgent Care or ER Visits

Submit claims for office visits, urgent care, or ER visits for the purpose of treating COVID-19 using ICD-10 primary diagnosis code of U07.1 regardless of the place of service. J12.82 should be used when treating patients who have pneumonia due to COVID-19.

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Maryland Department of Health and DC Health Release Coronavirus Guidance