COVID-19 Vaccine and Monoclonal Antibody Infusions Policy

POLICY NUMBER EFFECTIVE DATE APPROVED BY

R20200025 11/09/2020 RPC (Reimbursement Policy Committee) IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY: ConnectiCare has policies in place that reflect billing or claims payment processes unique to our health plans. Current billing and claims payment policies apply to all our products, unless otherwise noted. ConnectiCare will inform you of new policies or changes in policies through updates to the Provider Manual and/or provider news. The information presented in this policy is accurate and current as of the date of this publication. The information provided in ConnectiCare’s policies is intended to serve only as a general reference resource for services described and is not intended to address every aspect of a reimbursement situation. Other factors affecting reimbursement may supplement, modify or, in some cases, supersede this policy. These factors may include, but are not limited to: legislative mandates, physician or other provider contracts, the member’s benefit coverage documents and/or other reimbursement, medical or drug policies. Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems used by ConnectiCare due to programming or other constraints; however, ConnectiCare strives to minimize these variations. ConnectiCare follows coding edits that are based on industry sources, including, but not limited to; CPT guidelines from the American Medical Association, specialty organizations, and CMS including NCCI and MUE. In coding scenarios where there appears to be conflicts between sources, we will apply the edits we determine are appropriate. ConnectiCare uses industry-standard claims editing software products when making decisions about appropriate claim editing practices. Upon request, we will provide an explanation of how ConnectiCare handles specific coding issues. If appropriate coding/billing guidelines or current reimbursement policies are not followed, ConnectiCare may deny the claim and/or recoup claim payment.

Overview: The cost of COVID-19 FDA-authorized vaccine serums and monoclonal antibodies will initially be reimbursed by the government.

ConnectiCare will reimburse administration of FDA-authorized COVID-19 vaccines in accordance with applicable state and federal laws, regulations and guidance, including the the FFCRA, CARES Act and Emergency Use Authorization (EUA) guidance, as outlined below.

Medicare Advantage health plans: Charges for the COVID-19 vaccine administration should be billed to the CMS Medicare Administrative Contractor (Part B). The MAC will reimburse claims for Medicare members with no cost share for the remainder of 2020 and through 2021. Any claims for vaccines received for Medicare members will be denied informing the provider to resubmit to their MAC. For more information, see the CMS COVID-19 Insurers Toolkit.

Commercial and Exchange health plans: ConnectiCare will cover the administration of COVID- 19 vaccines with no cost share for in- and out-of-network providers, during the national public health emergency period. Administration fees will be based on contracted rates or CMS published rates.

Applicable Coding: CPT Code Description Q0239 • Injection, bamlanivimab-xxxx, 700 mg

COVID-19 Vaccine and Monoclonal Antibody Infusions Policy

CPT Code Description Q0243 Injection, casirivimab and imdevimab, 2400 mg M0201 COVID-19 vaccine home admin. Effective 6/08/2021

M0243 intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring M0244 Intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the COVID-19 public health emergency. Effective 5/6/2021 Q0245 Injection, bamlanivimab and etesevimab, 2100 mg Q0249 Injection, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, 1 mg. Effective 6/24/2021 M0245 intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring M0246 Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the covid-19 public health emergency. Effective 5/06/2021 M0247 Intravenous infusion, sotrovimab, includes infusion and post administration monitoring. Effective 5/26/2021 M0248 Intravenous infusion, sotrovimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the covid-19 public health emergency. Effective 5/06/2021 M0249 Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, first dose. Effective 6/24/2021 M0250 Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, second dose. Effective 6/24/2021 0001A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative

COVID-19 Vaccine and Monoclonal Antibody Infusions Policy

CPT Code Description free, 30 mcg/0.3mL dosage, diluent reconstituted; first dose (Pfizer- Biontech First Dose) 0002A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; second dose (Pfizer- Biontech Second Dose) 0003A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted; third dose (Pfizer-Biontech Covid-19 Vaccine Administration – Third Dose) Effective 8/12/2021 0011A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; first dose (Moderna-First Dose) 0012A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; second dose (Moderna-Second Dose) 0013A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; third dose (Moderna Covid-19 Vaccine Administration – Third Dose) Effective 8/12/2021 0031A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5x1010 viral particles/0.5mL dosage, single dose (Janssen Administration) 91300 Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted, for intramuscular use - Pfizer-BioNTech COVID-19 Vaccine 91301 Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative free, 100 mcg/0.5mL dosage, for intramuscular use - Moderna COVID-19 Vaccine 91303 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5x1010 viral particles/0.5mL dosage, for intramuscular use

COVID-19 Vaccine and Monoclonal Antibody Infusions Policy

CPT Code Description Revenue Code Both the monoclonal antibody and vaccines for COVID-19 should be 0771 coded under revenue code 0771 per CMS.

Revision history DATE REVISION 11/2020 • New Policy

02/2021 • Clarified that Contracted Rates will prevail before Medicare rates • Added correct Revenue code for billing

03/2021 • Added new codes 0031A, 91303, Q0245, M0245

5/2021 • Added new code M0244 (effective 5/6/2021); removed M0239 (effective 4/16/2021)

6/2021 • Added new codes M0246 & M0248 (effective 5/6/2021), M0247 (effective 5/26/2021) and M0201 (effective 6/08/2021)

8/2021 • Added new codes Q0249, M0249 & M0250 effective 6/24/2021

8/17/2021 • Added new codes 0003A & 0013A effective 8/12/2021