CurrentAnthemPolicy G-19001

Drug Screen Testing, Reimbursement Policy

Defines reimbursement rules for presumptive and definitive drug testing for Anthem HealthKeepers Plus Medicaid members, including when separate payment is allowed and nonreimbursable items. Applies to providers submitting claims under the HealthKeepers, Inc. benefit plan.

Policy Summary

PayerAnthem

PolicyDrug Screen Testing, Reimbursement Policy

Policy CodePolicy G-19001

Change TypeRemoved employment/pre-employment screeningclarified specimen validity

Effective Date08/06/2024

Next Review DateN/A

Key ActionDefinitive drug testing for 1–7 drug classes performed same day as presumptive testing may be reimbursed separately; 8+ classes require a subsequent order and are not separately reimbursed.

SourceLink

POLICY UPDATE CHANGES

The Health Plan does not allow reimbursement for employment/pre-employment drug screening was removed from the policy.

Policy language updated for clarity and to add language around specimen validity.

1-7drug classes separately reimbursable when definitive testing is on same date as presumptive

8+drug classes require subsequent order and not separately reimbursed when performed same date as presumptive

0separate reimbursement allowed for specimen validity testing

08/06/2024policy effective / last approval date

Reimbursement Criteria for Drug Testing

Drug testing reimbursement criteria

Reimbursement conditions for presumptive and definitive drug testing:

Presumptive and definitive drug testing are reimbursable when properly ordered and consistent with provider, state, federal, or CMS contracts and requirements.

When definitive testing is performed by an independent clinical laboratory (POS 81) on the same date of service as presumptive testing by instrumented chemistry analyzers for the same member, separate reimbursement is allowed for definitive testing covering one to seven drug classes.

Definitive drug testing for eight or more drug classes requires a subsequent order from the treating provider and will not be separately reimbursed if performed on the same date of service as presumptive testing.

Provider documentation and member medical records must reflect that the test was properly ordered; for confirmatory definitive testing, documentation should support that the order was based on the presumptive result.

Policy Summary

PayerAnthem

PolicyDrug Screen Testing, Reimbursement Policy

Policy CodePolicy G-19001

Change TypeRemoved employment/pre-employment screeningclarified specimen validity

Effective Date08/06/2024

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Codes, Thresholds, and Bundling Rules

Coding and bundlingmixedCovered

CPT/HCPCS

Use industry standard CPT and HCPCS codes for presumptive, definitive, and specimen validity testing as applicable; specimen validity testing is considered bundled into drug testing CPT/HCPCS codes.

Definitive drug test drug-class threshold for same-date separate reimbursement

Definitive drug‑class threshold (same‑date separate reimbursement)One to seven (1–7) drug classes are eligible for separate reimbursement when definitive testing is performed by an independent clinical laboratory (POS 81) on the same date as presumptive testing.

Threshold for non‑reimbursement same dateEight (8) or more drug classes require a subsequent order from the treating provider and will not be separately reimbursed when performed on the same date as presumptive testing.

Place of service requirementSeparate reimbursement allowance applies when definitive testing is performed by an independent clinical laboratory (POS 81).

Provider Billing and Documentation Requirements

Billing Rule

Same‑day definitive vs presumptive testing reimbursement

When definitive drug testing is performed by an independent clinical laboratory (POS 81) on the same date of service as presumptive drug testing, separate reimbursement is allowed only for definitive testing that covers one to seven drug classes; definitive testing for eight or more drug classes requires a subsequent order from the treating provider and will not be separately reimbursed if performed on the same date as presumptive testing.

Same‑date separate reimbursement allowed: definitive testing covering 1–7 drug classes.
Same‑date separate reimbursement denied: definitive testing covering 8+ drug classes unless there is a subsequent treating provider order.

Documentation Required

Documentation requirement

Provider documentation and the member's medical record must show that definitive tests were properly ordered; if the definitive test is confirmatory, documentation must support that the order was based on the presumptive result.

Document that the definitive test was ordered appropriately.
For confirmatory definitive testing, document that the order was based on the presumptive test result.

Key Definitions

Presumptive/Qualitative Drug Testing

DefinitionUsed to determine the presence or absence of drugs or drug classes in a urine sample; results expressed as negative or positive or as a numerical result.

PurposeScreening to detect potential drug exposure prior to confirmation by definitive methods.

Reimbursement notePresumptive drug testing is reimbursable when properly ordered and consistent with provider, state, federal, or CMS contracts and requirements.

Definitive/Quantitative Drug Testing

DefinitionUsed to identify specific medications, illicit substances, and metabolites; reports analytes present or absent typically in concentrations such as ng/ml.

Use caseMay be used to detect specific substances not identified by presumptive methods and to refine the accuracy of presumptive test results.

Documentation requirementProvider documentation and member medical records should reflect that definitive tests were properly ordered; for confirmatory definitive testing, documentation should support that the order was based on the presumptive result.

Specimen Validity Testing

DefinitionUrine specimen testing to ensure consistency with normal human urine and detect adulteration or substitution (may include pH, specific gravity, oxidants, creatinine).

Billing treatmentSpecimen validity testing is included in presumptive and definitive drug testing CPT and HCPCS code descriptions and is not separately reimbursable.

ModifiersNo modifiers will override the bundle edit to allow separate reimbursement for specimen validity testing.