CurrentBlue Cross Blue Shield - MainePolicy G-19001

Drug Screen Testing (Reimbursement)

This reimbursement policy governs coverage and billing for presumptive and definitive drug screening and specimen validity testing for AMH Health (Medicare Advantage) members and providers submitting claims to Blue Cross Blue Shield - Maine.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyDrug Screen Testing (Reimbursement)

Policy CodePolicy G-19001

Change TypeMaterial and clarifying revisions

Effective Date08/06/2024

Next Review Date

Key ActionProviders must document that definitive testing orders are based on presumptive test results when definitive testing is confirmatory.

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 to not allow separate reimbursement for specimen validity testing (included in presumptive and definitive codes).

Reimbursement allowed for presumptive and definitive testing when appropriate and when provided by an independent clinical laboratory (POS 81) on the same day for the same member.

G-19001Policy identifier

08/06/2024Effective / Last Approval

IncludedSpecimen validity testing

Allows same-day POS 81Coverage arrangement

Coverage Criteria for Drug Testing

Drug testing coverage criteria

Covered when ALL of the following are met:

Reimbursement allowed for presumptive and definitive drug testing when provider, state, federal, and CMS contracts and/or requirements do not indicate otherwise.

Presumptive and definitive testing are allowed for the same member on the same day when performed by an independent clinical laboratory (POS 81).

Definitive drug testing is used when necessary to detect specific substances not identified by presumptive methods or to refine the accuracy of presumptive results.

When definitive testing is performed as confirmatory, provider documentation and the member's medical record must support that the definitive test was ordered based on the presumptive test result.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyDrug Screen Testing (Reimbursement)

Policy CodePolicy G-19001

Change TypeMaterial and clarifying revisions

Effective Date08/06/2024

Next Review Date

Key ActionProviders must document that definitive testing orders are based on presumptive test results when definitive testing is confirmatory.

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.

Billing Codes and Compliance

Drug testing codesmixedCovered

Presumptive and definitive drug testing CPT/HCPCS

Policy references use of CPT and HCPCS codes; specimen validity testing is included in these code descriptions and not separately reimbursable.

Billing compliance

Billing standardUse industry-standard, compliant CPT, HCPCS, and/or revenue codes on all claim submissions; codes must be fully supported in the medical record or office notes.

Documentation requirementServices billed must be supported by documentation demonstrating medical necessity and authorization where applicable.

Noncompliance consequencesIf coding/billing guidelines are not followed, AMH Health may reject or deny the claim, recover/recoup payment, or adjust reimbursement to reflect appropriate services performed.

ApplicabilityReimbursement policies apply to both participating and non-participating professional providers and facilities unless otherwise noted.

Documentation and Provider Requirements

Documentation Required

Document that definitive testing was ordered based on presumptive results

For definitive (confirmatory) testing, document in the member’s medical record that the definitive test was ordered based on the presumptive test result. Medical records and provider documentation must reflect that the definitive test was properly ordered and indicate the presumptive result that prompted confirmation. Services must meet authorization and medical necessity guidelines.

Record the presumptive test result that prompted the definitive/confirmatory test.
Ensure member medical records show the definitive test was properly ordered as confirmation.
Confirm services meet authorization and medical necessity requirements.

Key Definitions

Presumptive/Qualitative Drug Testing

DefinitionPresumptive (Qualitative) Drug Testing is used to determine the presence or absence of drugs or drug classes in a urine sample; results are expressed qualitatively.

Typical useUsed as an initial screen to detect drug classes before confirmatory testing.

Result formatReported as presence/absence (qualitative), not concentrations.

Definitive/Quantitative Drug Testing

DefinitionDefinitive (Quantitative) Drug Testing is used to identify specific medications, illicit substances, and metabolites and reports analyte concentrations (typically in ng/mL).

Typical useUsed to confirm and quantify substances not specifically identified by presumptive methods or to provide concentration data.

Result formatReports presence/absence and numeric concentration values for specific analytes.

Specimen Validity Testing

DefinitionSpecimen Validity Testing is urine testing to ensure a specimen is consistent with normal human urine and has not been adulterated or substituted; may include pH, specific gravity, oxidants, and creatinine.

Reimbursement stanceSpecimen validity testing is included in presumptive and definitive CPT/HCPCS code descriptions and is not separately reimbursable.

Typical componentsMay include, but is not limited to, pH, specific gravity, oxidant testing, and creatinine measurement to assess sample integrity.