MedicaidCoverageHigh impact
Oregon Health Plan coverage of COVID-19 antibody testing
Oregon Health Plan·OR · Pediatrics, Emergency Medicine, Critical Care +2 more·Plan
Effective date
Jun 8, 2020
We identified it
Aug 19, 2026
Summary
Oregon Health Plan (OHP) now covers COVID-19 antibody testing ONLY when using FDA EUA/approved tests to evaluate hospitalized children under age 21 for multisystem inflammatory syndrome (MIS-C). All other antibody testing uses are non-covered. Two specific billing codes are authorized for compliant testing with established reimbursement rates.
Action Required
Immediately: Billing team must restrict COVID-19 antibody testing claims to OHP members under the new coverage criteria (hospitalized patients under age 21 being evaluated for MIS-C only). Update billing system to flag non-compliant antibody tests for rejection before submission. Configure system to accept only CPT 86328 ($45.23) and CPT 86769 ($42.13) when strict criteria are met. Providers must document patient age (under 21), hospitalization status, and MIS-C evaluation indication in medical record before billing. All other COVID-19 antibody testing requests should be denied or coded as patient responsibility. Communicate policy change to all OHP-contracted providers and clinical staff. Any antibody tests submitted outside these parameters will be denied by OHP and create claim rework.