Coverage of Emergency COVID-19 Inpatient or Outpatient Services

April 8, 2020

As the COVID-19 situation continues to evolve, the Department of Health Care Services (DHCS) continues to closely monitor and assess appropriate next steps as well as release guidance to ensure the safety of Medi-Cal beneficiaries, Medi-Cal providers, and California communities in general. DHCS is committed to ensuring that all Medi-Cal beneficiaries have access to medically necessary COVID-19 testing and if needed, medical treatment.

Emergency inpatient or outpatient medical services are covered benefits for all enrolled Medi-Cal beneficiaries, including enrolled undocumented beneficiaries, when necessary to treat an emergency medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, which in the absence of immediate medical attention could reasonably be expected to result in any of the following:

  • Placing the patient’s health in serious jeopardy;
  • Serious impairment to bodily functions; or
  • Serious dysfunction to any bodily organ or part.

Due to the ongoing public health emergency, COVID-19 testing and related medically necessary treatment services, including services rendered outside of a hospital emergency department, are hereby deemed to be emergency services to treat an emergency medical condition. Accordingly, all enrolled Medi-Cal beneficiaries, regardless of their scope of coverage under Medi-Cal or documentation status, are entitled to all inpatient and outpatient services necessary for the testing and treatment of COVID-19 as certified by the attending physician or other appropriate provider and in the same manner as administered under Section 51056 of Title 22 of the California Code of Regulations. Continuation of medically necessary inpatient hospital services and follow up care after the emergency has resolved shall not be authorized or reimbursed for undocumented Medi-Cal beneficiaries enrolled for only restricted scope benefits. There is no copay for emergency services including testing, evaluation and treatment for COVID-19.

When billing for emergency COVID-19 testing and treatment services in an office or outpatient setting, providers should report Emergency Indicator = Y in field 24 C of the CMS-1500 form and Emergency Indicator = “81” on the UB 04 form. When billing for emergency COVID-19 testing and treatment services in an institutional setting (emergency department, hospital outpatient/diagnostic and treatment center, and hospital inpatient) and in federally qualified health centers, rural health centers, and tribal health 638 clinics, providers should report Type of Admission Code = 1 in field 14 of the UB 04 form to indicate an emergency. Providers must indicate emergency treatment on the claim and submit the following statement: “Patient impacted by COVID-19” and include relevant clinical information about the patient's condition and why the emergency services rendered were considered immediately necessary. The statement must be signed by the provider. Refer to the claim completion section of the appropriate Part 2 manual for specific claim form instructions.

Additionally, all acute level inpatient days (except an emergency admission for labor and delivery) continue to require authorization via a Treatment Authorization Request (TAR). DHCS released a COVID-19 prior authorization (PA) notice to inform providers of the approved waiver flexibilities that suspends fee-for-service PA requirements, effective March 1, 2020, until termination of the COVID-19 public health emergency.

Additional Resources

For additional COVID-19 information and resources, we encourage you to review the following resources: