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

The Administration is providing support to health care providers fighting the COVID-19 pandemic through 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 reimbursements on a rolling basis directly to eligible providers for claims attributed to the testing, treatment, or vaccine administration for COVID-19 for uninsured individuals.

The following parts of bipartisan legislation provide funding for the program:

• The Families First Coronavirus Response Act or FFCRA (P.L. 116-127) and the Paycheck Protection Program and Health Care Enhancement Act or PPPHCEA (P.L. 116-139), which each appropriated $1 billion to reimburse providers for conducting COVID-19 testing for uninsured individuals;
• The Coronavirus Aid, Relief, and Economic Security (CARES) Act (P.L. 116-136), which provided $100 billion in relief funds, including to hospitals and other health care providers on the front lines of the COVID-19 response; the Paycheck Protection Program and Health Care Enhancement Act or PPPHCEA (P.L. 116-139), which appropriated an additional $75 billion in relief funds; and the Coronavirus Response and Relief Supplemental Appropriations Act (CRRSA) (P.L. 116-260), which appropriated an additional $3 billion (collectively, the Provider Relief Fund).
  • Within the Provider Relief Fund, a portion of the funding supports health care-related expenses attributable to COVID-19 testing for the uninsured and treatment of uninsured individuals with COVID-19. A portion of the funding is also used to reimburse providers for administering Food and Drug Administration (FDA)-authorized or licensed COVID-19 vaccines to uninsured individuals.
• The American Rescue Plan Act of 2021 (ARPA, P.L. 117-2), which allocated funding to reimburse providers for COVID-19 testing of the uninsured.

Initially, the Families First Coronavirus Response Act (FFCRA) and the PPPHCEA each appropriated $1 billion to reimburse providers for conducting COVID-19 testing for uninsured individuals. Funding allocated from the FFCRA and PPPHCEA for reimbursing provider claims for COVID-19 testing of the uninsured has been fully disbursed. The HRSA COVID-19 Uninsured Program now draws from funding allocated through the American Rescue Plan Act of 2021 (ARPA, P.L. 117-2) and the legislation that supports the Provider Relief Fund, as explained elsewhere in the FAQs.

The program is being administered by the U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA) through a contract with UnitedHealth Group.

No. The HRSA COVID-19 Uninsured Program is a claims reimbursement program for health care providers which does not meet the definition of a “health plan” as defined in section 1171(5) of the Social Security Act and in 45 C.F.R. § 160.103 in that the program has no relationship with individuals that would legally obligate the program to pay claims for some or all of the health care provided to those individuals. Therefore, the program is not subject to HIPAA requirements.

The HRSA COVID-19 Uninsured Program does not provide coding guidance to providers. Rather, the program provides billing guidance to allow providers to identify and submit only claims eligible for reimbursement under this program, which is exclusively for reimbursing providers for COVID-19 testing of uninsured individuals and treatment for uninsured individuals when COVID-19 is the primary reason for treatment, or for vaccine administration to uninsured individuals. HRSA has developed the following guidance for claims reimbursement submission:

• For dates of service or discharges on or after April 1, 2020, providers will use primary diagnosis U07.1 to indicate COVID-19 is the primary reason for treatment except for pregnancy for which providers will use O98.5 as primary diagnosis and U07.1 as the secondary diagnosis.
• For dates of services or discharges prior to April 1, 2020, there is no equivalent diagnosis to indicate COVID-19 is the primary reason for treatment. To address this issue, HRSA has established separate guidance for this program to use B97.29 as the primary diagnosis when COVID-19 is the primary reason for treatment except for pregnancy for which providers would use O98.5 as the primary diagnosis and B97.29 as the secondary diagnosis (similar to how U07.1 is used).

HRSA recognizes that the use of B97.29 as the primary diagnosis as described above is different from the ICD-10-CM Official Coding Guidelines – Supplement for Coding encounters related to COVID-19 Coronavirus Outbreak. However, as previously stated, HRSA’s COVID-19 Uninsured Program is not a health plan.

Yes. Individuals who have only foreign health coverage or are uninsured are considered uninsured individuals for the purposes of vaccine administration claims reimbursement in the Uninsured Program, as foreign health coverage may be impossible or not feasible to ascertain. Providers who administer FDA-authorized or licensed COVID-19 vaccines to individuals whose only health care coverage at the time the vaccine was administered was foreign health coverage may submit vaccine administration claims to the Uninsured Program.

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) 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 - 317 KB).

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 - 94 KB). For more information on strategies to assist states in operationalizing this group, see this guidance (PDF - 244 KB).

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.

No. The terms and conditions for receipt of claims reimbursement payments from the COVID-19 Uninsured Program require the recipient to certify that it will not use the payment to reimburse expenses or losses that have been reimbursed from other sources. If another source, including a hospital charity program, has already reimbursed the provider for the cost of the treatment, then the provider cannot submit a claim for reimbursement to the COVID-19 Uninsured Program. However, if the hospital charity program covered some, but not all, of the cost of an uninsured individual’s treatment for COVID-19, then a provider may submit a claim for reimbursement for the cost of the treatment that was not covered by the hospital charity program.

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)) of the Uninsured Program.

Any provider who is on the Office of the Inspector General U.S. Department of Health and Human Services List of Excluded Individuals/Entities; currently terminated from participation in Medicare or precluded from receiving payment through Medicare Advantage or Part D; currently excluded from participation in Medicare, Medicaid, or other Federal health care programs; and/or has Medicare billing privileges revoked is ineligible to receive funding from the COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for 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.

For more details, see billing codes information.

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 testing-related visit (the admission) is not eligible for reimbursement because the care setting is not an office visit, telehealth visit, urgent care or emergency room and is not separately billable with applicable CPT/HCPCS codes on the inpatient claim. Unless COVID-19 is the primary diagnosis for the admission, no portion of this claim is eligible for reimbursement under the program 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

No. Since the primary reason for treatment was cancer and not COVID-19, the cancer treatment is not eligible for reimbursement.

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.

The ICD-10-CM Official Coding Guidelines – Supplement for Coding encounters related to COVID-19 Coronavirus Outbreak do not apply to the HRSA Uninsured COVID 19 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.

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, 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.

No.  Under the terms of the CDC COVID-19 Vaccination Program Provider Agreement signed by providers, the provider may not bill a patient any amount for the vaccine or its administration.  All organizations and providers participating in the CDC COVID-19 Vaccination Program (which currently includes any providers who may be administering the vaccine) may not seek any payment, including through cost sharing requirements or any balance billing, from the vaccine recipient for the vaccine or its administration.  This does not change, even if the patient is enrolled in Marketplace coverage and is in a grace period.  A grace period is a short period — three months if the policy is receiving the benefit of APTC, or a different period as specified in state law for other policies — provided to a consumer who fails to make the monthly health insurance premium payment by the due date before the policy is terminated. If a consumer has not made their premium payment, they have until the end of the grace period to pay back all outstanding premium to avoid losing their health coverage. The grace period for health insurance is three months if the enrollment is receiving the benefit of APTC when the premium payment is missed.  Normally if an enrollee in a qualified health plan who is receiving the benefit of APTC has a pended claim during month 2 or 3 of a grace period (or if an enrollee is not receiving APTC and has a pended claim during a state grace period typically lasting 30 days)*, and the claim is ultimately denied because of termination of the enrollee’s coverage, the enrollee would be responsible for the claim.  However, this does not permit the provider to seek payments from the patient that would be prohibited by the terms of the CDC COVID-19 Vaccination Program.

* The length of the grace period may be different if the consumer does not qualify for a premium tax credit and the State Department of Insurance (DOI) has information on grace periods in the state.

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.

The HRSA COVID-19 Uninsured Program aligns claims reimbursement for monoclonal antibody therapy with the CMS guidance issued on November 10, 2020. Per CMS’s Medicare Monoclonal Antibody COVID-19 Infusion Program Instruction, “During the COVID-19 public health emergency (PHE), Medicare will cover and pay for these infusions the same way it covers and pays for COVID-19 vaccines (when furnished consistent with the EUA).” Information regarding coding and pricing can be found in the Medicare Monoclonal Antibody COVID-19 Infusion Program Instruction (PDF - 70 KB).

On January 1, 2021, Medicare began reimbursing independent laboratories $75 per COVID-19 PCR testing claim (HCPCS codes U0003 and U0004) with a potential add-on reimbursement of $25 (HCPCS code U0005) if the laboratory returned COVID-19 PCR testing results to patients within 48 hours and returned results for a majority of its non-COVID-19 PCR tests (Medicare and non-Medicare) during the previous calendar month within two days. However, the HRSA COVID-19 Uninsured Program continues to reimburse independent laboratories at a rate of $100 for COVID-19 PCR testing claims with HCPCS codes U0003 and U0004 and did not implement the add-on reimbursement for HCPCS U0005 on January 1, 2021.

Health care providers who have conducted COVID-19 testing for uninsured individuals, provided treatment to uninsured individuals with a primary COVID-19 diagnosis on or after February 4, 2020, or administered an FDA-authorized or licensed COVID-19 vaccine to uninsured individuals, can request claims reimbursement through the program electronically and are reimbursed generally at Medicare rates, subject to available funding. Steps will involve: enrolling as a provider participant, checking patient eligibility, submitting patient information, submitting claims, and receiving payment via direct deposit.

To participate, providers must attest to the following at registration:

• They have checked for health care coverage eligibility and confirmed that the patient is uninsured. They have verified that the patient does not have health care coverage, and no other payer will reimburse them for COVID-19 testing and/or care or vaccine administration for that patient.
• They will accept defined program reimbursement as payment in full.
• They will agree not to balance bill the patient.
• They will agree to program terms and conditions and may be subject to post-reimbursement audit review.

All claims submitted must be complete and final, and no interim bills or corrected claims are accepted. There are no adjustments to payment once claims reimbursements are made.

Eligible providers began enrolling in the program on April 27, 2020, and submitting claims on May 6, 2020. The majority of claims are reimbursed within 30 days.

Information on claims submission can be found at: COVID-19 Claims Reimbursement.

Providers should submit the following patient information as part of the HRSA COVID-19 Uninsured Program:

• First and last name
• Date of birth
• Gender
• *SSN and state of residence; if not available, enter state identification / driver's license
• Date of service for professional, institutional outpatient services.
• Date of admission and date of discharge for institutional inpatient services.
• **Address
• Middle initial (optional)
• Patient account number (optional)

* A SSN and state of residence, or state identification / driver’s license is needed only for the purpose of verifying insurance status. If a SSN and state of residence, or state identification / driver’s license is not submitted, you will need to attest that you attempted to capture this information before submitting a claim and the patient did not have this information at the time of service, or that you did not have direct contact with the patient and thus did not have an opportunity to attempt to capture this information.

**If the individual is unable or unwilling to provide their address, please add the address of the facility where the care was provided or other location that may be appropriate (e.g., shelter).

For professional and institutional outpatient – Temporary member ID is valid for 120 days from date of service. Eligible claims can be submitted using the temporary member ID with date of service within the validity period. For example, if Patient A had a date of service of February 4, 2020, then the temporary ID assigned to her is valid from February 4, 2020, through June 3, 2020.

For institutional inpatient – Temporary member ID is valid from date of admission and expires 120 days from date of discharge. Eligible claims can be submitted using the temporary member ID with date of admission and date of discharge within the validity period. For example, if Patient B had a date of admission of February 4, 2020, and date of discharge of February 20, 2020, then the temporary member ID assigned to him is valid from February 4, 2020, through June 19, 2020. Note: If an uninsured individual was treated in the ER before being admitted as an inpatient, use the date of admittance to the ER as the inpatient admittance date.

Claims can still be submitted after the date of validity, but the temporary member ID must be eligible for the date of service or admittance.

No. All claims submissions and claims reimbursements must be submitted and remitted electronically.

No. These are claims reimbursements, not loans, to health care providers, and will not need to be repaid, provided applicable terms and conditions are met and except when it is later determined that the payments were to ineligible providers or for ineligible beneficiaries or costs.

Reimbursement pricing and policies under this program for eligible services, as determined by HRSA (subject to adjustment as may be necessary), are described below.

• Reimbursement is based on the current year Medicare fee schedule rates except where otherwise noted.
• Publication of new codes and updates to existing codes is made in accordance with published CMS guidance.
• For any new codes where a CMS published rate does not exist, claims are held until CMS publishes corresponding reimbursement information.
• Claims submitted electronically for professional services are priced as follows:
  • Services are priced with current-year CMS pricing with geographic adjustments, as applicable.
  • If no geographic adjustments are applicable, services are priced with current-year CMS national pricing.
  • COVID-19 testing and specimen collection procedures are priced in accordance with CARES Act (PDF) requirements and rates published in CMS interim final rules.
• Claims submitted electronically for facility services are generally priced according to traditional Medicare reimbursement, examples of exceptions are noted below:
  • For purposes of this program, facility reimbursement based on IPPS does not include the 20% increase to the DRG weight for COVID-19 diagnoses U07.1 and B97.29 authorized by Section 3710 of the Cares Act.
  • For purposes of this program, reimbursement rates for facilities not paid on IPPS [Critical Access Hospitals (CAHs), Rural Health Clinics (RHCs), Children’s Hospitals, and PPS Exempt Cancer Hospitals] are not updated after February 4, 2020.
  • Home health services are priced based on a per-visit methodology by service type as established by the program:
    • All Medicare-eligible service categories: PT/OT/ST - $90
    • Nursing services – skilled nursing - $90
    • Nursing services – licensed practical nurse - $60
    • Medical social services - $90
    • Home health aide - $30
    • Home infusion therapy – PICC/midline supplies $70, PICC/midline placement $110
• For purposes of this program, the following rates apply for reimbursement of ambulance claims with a primary diagnosis of COVID-19:
  • Ground ambulance: facility price of $350 per claim; professional claims price at current year CMS pricing with geographic adjustments as applicable
  • Water ambulance: facility price of $350 per claim; professional claims price at current year CMS pricing with geographic adjustments as applicable
  • Air ambulance: facility price of $2,300 per claim; professional claims price at current year CMS pricing with geographic adjustments as applicable
• The dispensing fee for FDA-licensed or authorized outpatient antiviral drugs for treatment of COVID-19 is priced at $12 without geographic adjustment.

FDA-licensed or authorized vaccine administration fees are priced based on national Medicare rates and are outlined below. For guidance on eligibility and billing for vaccine administration, refer to the Centers for Disease Control and Prevention (CDC) and Centers for Medicare & Medicaid Services (CMS) websites.

• For dates of service through March 14, 2021:
  • Administration of the final dose of a COVID-19 vaccine requiring a series of two or more doses - $28.39
  • Administration of the first dose of a COVID-19 vaccine requiring a series of two or more doses - $16.94
  • Administration of a single-dose COVID-19 vaccine - $28.39
• For dates of service on or after March 15, 2021:
  • Administration (per dose) of a COVID-19 vaccine - $40.00
  • For guidance on eligibility and billing for booster shots and additional doses of the vaccine, refer to the CDC website.
• For COVID-19 vaccinations administered in-home* with dates of service on or after June 8, 2021:
  • Administration (per dose) of a COVID-19 vaccine - $75.50
  • For guidance on eligibility and billing for booster shots and additional doses of the vaccine, refer to the CDC website.
  • *Note: In-home vaccine administration claims must be submitted with two codes to be eligible for reimbursement:
    • The first code must be one of the following:
      • Pfizer: 0001A, 0002A, 0003A, 0004A, 0071A, 0072A, 0073A
      • Moderna: 0011A, 0012A, 0013A, 064A
      • Janssen: 0031A, 0034A
    • The second code must be M0201 (COVID-19 vaccine home administration)
    • For a definition of what constitutes in-home administration, see this CMS fact sheet (PDF - 138 KB).

No. For the HRSA COVID-19 Uninsured Program, facility reimbursement based on IPPS does not include the 20% increase to the DRG weight for COVID-19 diagnoses U07.1 and B97.29 authorized by Section 3710 of the CARES Act.

Yes. The program reimburses providers for COVID-19 testing, treatment, or vaccine administration fees for uninsured individuals; therefore, any money collected from the individual must be returned to the individual if the provider received funding for that patient through this program.

This requirement is included in the Terms and Conditions that the provider signs in order to enroll in the program.

You can download an 835 file, as well as download the Electronic Provider Remittance Advice (PDF version of the 835 file) for the HRSA COVID-19 Uninsured Program, by accessing Optum Pay™ with your Optum ID. On the Optum Pay website you can access your remittance information on the View Payments tab. You can find that tab by following this path:

• Log in to Optum Pay.
• Select the Tax Identification Number (TIN) associated with the claims you are looking to reconcile.
• Select View Payments.

You will need to access the 835 file in order to upload it into your practice management system. This will allow you to reconcile your claims as you would if you had received the 835 file via your clearinghouse. Please allow for appropriate processing time. As part of the HRSA COVID-19 Uninsured Program, the 835 file will not be electronically routed to you from your clearinghouse.

Multiple individuals in an organization can have an Optum ID, but only one person per TIN can serve as the administrator. If the portal indicates that the TIN you entered already has an administrator and you cannot identify that individual, please call 866-569-3522. We will work with your organization to identify the correct TIN administrator and reassign this role after appropriate security requirements are met.

As part of the HRSA COVID-19 Uninsured Program, the 835 file will not be electronically routed to you from your clearinghouse.

The program identifies overpayments and has a process in place to collect the overpaid funds from future claims payments related to the HRSA COVID-19 Uninsured Program. Alternatively, providers who self-identify an overpayment can send a check to return the funds. Providers must complete this form (PDF - 134 KB) and include it with their check to ensure funds are applied appropriately. Checks should be made payable to UnitedHealthcare and submitted with any supporting documentation.

Send Checks/Forms for Returned Funds to:

UnitedHealthcare
PO Box 101760
Atlanta, GA 30392-1760

Payments received from the program are claims reimbursements and should be treated in the same manner as reimbursements received from commercial insurance, Medicaid, and/or Medicare, including in how revenue or losses are determined. See guidance issued by the Centers for Medicare & Medicaid Services (PDF - 1 MB) on how providers should report claims reimbursed through the HRSA COVID-19 Uninsured Program on the S-10 worksheet.

The UIP provides reimbursements to eligible providers/pharmacies for claims attributed to the testing, treatment, or vaccine administration for COVID-19 for uninsured individuals. NCPDP claims are not accepted. Pharmacy providers need to enroll in the UIP portal. Once enrolled, claims should be submitted for reimbursement electronically outside of the program portal through the medical EDI 837 process (PDF) using Payer ID 95964 (COVID19 HRSA Uninsured Testing and Treatment Fund). This is similar to billing COVID-19 vaccines to the Medicare medical benefit instead of the pharmacy benefit. More information on the claim submission process can be found under Claims & Reimbursement or on our provider checklist.

A clearinghouse/medical intermediary is an organization that enables the exchange of healthcare data between the provider and the payer (insurance company). It is the only HIPAA covered entity that can translate between standard and non-standard transaction formats. As such, clearinghouses/medical intermediaries provide solutions that enable data submission from provider systems into the HIPAA 837 claim format required for claims submission and payment as part of this program. This can expedite the overall turnaround time from claim submission to payment.

See our list of Uninsured Program (UIP) participating clearinghouses/medical intermediaries (PDF). Providers that utilize a clearinghouse/medical intermediary not listed should contact their current vendor to ensure they establish a partnership with one of UIP’s designated clearinghouses/medical intermediaries.

No. Providers/pharmacies need to enroll in the UIP portal and complete initial steps, such as validating their provider TIN and adding their provider roster, but other steps, like registering for direct deposit/ACH through Optum Pay™ and submitting claims, must be done outside of the program portal. See our provider checklist for a step-by-step guide on how and where to complete the process, expected timeframes, and links to helpful resources.

No. Pharmacies will typically fill out the tab titled “Hospital_Ancillary_Clinic”. If the “Hospital_Ancillary_Clinic” tab is completed, individual pharmacists do not need to be listed on the provider roster. If a pharmacy’s National Provider Identifier (NPI) is assigned per service location and claims are billed at this level, the provider should complete the “Hospital_Ancillary_Clinic” tab and fill out one row per taxpayer identification number (TIN)/NPI/service location.

No. The Uninsured Program utilizes Optum Pay™ (through OptumBank®) as the administrator of direct deposits/automated clearing house (ACH) setups and payments to providers. This is not the same as OptumRx®, the Pharmacy Benefit Manager (PBM) for pharmacy benefits.

Pharmacies/pharmacists and those operating under their supervision who are legally authorized, including those authorized by operation of the Public Readiness and Emergency Preparedness (PREP) Act, to order and/or administer testing or vaccination services are eligible to request reimbursement for testing or vaccination administration under this program.