ᏗᎾᏓᏁᏢᏍᎩ

CPP 161: Polymerase Chain Reaction Respiratory Viral Panel Testing

06/04/2021

WellCare is implementing the following policy for Polymerase Chain Reaction Respiratory Viral Panel Testing with an effective date as of July 12, 2021.

Summary of Policy:

Policy/Criteria 

I.  It is the current policy of WellCare Health Plans that respiratory viral panels (RVPs) testing for five pathogens or less are considered medically necessary when meeting one of the following:

A.  Performed in the outpatient setting, will influence the plan of care, and any of the following:

1. To assess for infection by other pathogens when COVID-19 is suspected and a COVID-19-specific test result will not be available soon enough to influence the plan of care;
2. The member is immunocompromised;
3. The test is ordered by an infectious disease specialist, or an infectious disease specialist is not available;

B.  Performed in a healthcare setting that cares for critically ill patients, such as the emergency department or inpatient hospital, including those in observation status.

II.  It is the new policy that respiratory viral panels (RVPs) testing for six pathogens or more are considered medically necessary in a healthcare setting that cares for critically ill patients, such as the emergency department or inpatient hospital, including those in observation status.

III.  It is the new policy that RVPs are considered not medically necessary for all other indications.

What does this mean for providers?

Providers may see denials for claims billed outside of the criteria stated above for this policy.

WellCare is committed to assisting the provider during this time of adjustment. Additional information regarding the policy will be made available during the implementation process.

If a provider does not agree with WellCare’s decision, they may dispute or appeal the denial. WellCare will require medical records that substantiate provider billing.

Providers can review the complete policy at https://www.wellcare.com/Kentucky/Providers, select Claims, then Payment Policy.

We are here to help. Please contact your Network Representative for general inquiries regarding this program.