COVID-19 testing is a covered benefit when medically necessary. Beneficiaries suspected to have COVID-19 should be tested following Centers for Disease Control and Prevention (CDC) guidelines. Tests must meet Families First Coronavirus Response Act (FFCRA) criteria.
Testing required prior to a procedure or admission may be considered medically necessary and appropriate.
Visit TRICARE’s Coronavirus Testing Coverage page for benefit details based on beneficiary category (for example, active duty, retired, etc.).
Diagnostic testing is covered when medically necessary.
Additionally, in vitro diagnostic tests using Reverse Transcription Polymerase Chain Reaction (RTPCR) for asymptomatic active duty service members may also be considered for coverage when ordered by a TRICARE-authorized provider.
Antibody (Serology) Testing
To be considered for coverage, antibody tests must be rendered to diagnose and/or treat beneficiaries. Antibody tests are not a covered benefit when performed:
- on asymptomatic patients;
- to satisfy patient curiosity;
- to determine a patient's ability to return to work or school;
- to determine a donor’s ability to donate blood or plasma; and/or
- as part of epidemiological research, surveillance studies or for other public health reason.
If requesting a benefit review for an antibody (serology) test, providers may attach a Letter of Attestation in lieu of clinical documentation to the request.
There are no approval requirements specific to testing from Health Net Federal Services, LLC. There are no utilization limits for how often a test can be provided, however it must be medically necessary and appropriate as indicated above.
Our claims system is updated regularly to include added Current Procedural Terminology (CPT®) and Common Procedure Coding System (HCPCS) codes. Claims may be delayed to allow for appropriate code approval and system updates.
Beneficiary copayments/cost-shares are waived for COVID-19 diagnostic and antibody testing and related services, and office visits, urgent care or emergency room visits (to include covered telemedicine) during which tests are ordered or administered.
See scenarios below for additional clarification.
- Example 1: Patient visits a provider with flu-like symptoms. A flu test is administered and tests positive. Provider does not order a COVID-19 diagnostic test.
Result: Copayments and cost-shares shall not be waived.
- Example 2: Patient visits an out-of-network primary care provider with flu-like symptoms. A flu test is administered and tests negative. Patient is referred for a COVID-19 diagnostic test. Because the patient is diabetic, the physician orders a laboratory test for an A1C level check and the patient is evaluated for a diabetic ulcer.
Result: The out-of-network cost-share for the visit, the flu test and the COVID-19 diagnostic test shall be waived. The cost-share for the out-of-network A1C test shall not be waived.
- Example 3: Patient visits the emergency room with a broken leg. While evaluating the patient, the doctor identifies symptoms of COVID-19 and orders a COVID-19 diagnostic test.
Result: The copayment/cost-share for the visit and the test shall be waived, but any copayments/cost-shares associated solely with the diagnosis and treatment of the broken leg shall not be waived (for example, X-rays and casting of the leg, DME-related cost-shares for crutches).