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.
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 |
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 |
M0243 (casirivimab and imdevimab) |
| On or after November 21, 2020 |
Q0243 (Injection, casirivimab and imdevimab, 2400 mg) | |
|
On or after |
M0245 (intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring) |
|
|
On or after |
Q0245 (injection, bamlanivimab and etesevimab, 2100 mg) |
|
| On or after May 6, 2021 |
M0244 (Intravenous infusion or subcuteaneous 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 |
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 |
Q0240 (Injection, casirivimab and imdevimab, 600 mg) | |
|
On or after |
HCPCS codes: |
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
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 |
|
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 |
| High Throughput Diagnostic Testing |
On or after April 14, 2020 |
HCPCS codes U0003 or U0004 |
| 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 |
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 |
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
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
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.