ModifiedBlue Cross Blue Shield - New MexicoPolicy CPCPLABO1S

Hepatitis Testing

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Blue Cross Blue Shield of New Mexico policy defining laboratory reimbursement and coverage criteria for hepatitis A, B, C, and D testing across member products; applies to providers submitting claims for hepatitis-related lab testing.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyHepatitis Testing

Policy CodePolicy CPCPLABO1S

Change TypeMaterial updates to coverage, frequency, and coding

Effective DateJul 25, 2025

Last ReviewJul 25, 2025

Next Review Date

Key ActionReview product-specific Plan documents and verify prior authorization requirements and coding before submitting claims for the added test codes.

SourceLink

POLICY UPDATE CHANGES

Antibody testing for HCV once every three months may be reimbursable for individuals with ongoing risk factors such as receiving immunosuppressant therapy.

Qualitative nucleic acid testing for HCV may be reimbursable in specified situations; age range for one-time screening of perinatally exposed infants changed from 2-17 to 2-6 months.

New language specifying reimbursable testing for hepatitis A and hepatitis D and stating quantitative viral load testing for HAV and HDV is not reimbursable.

Added codes 86692, 86708, 86709, 87380, 87523, 87516, 87799 to the policy.

Under Hepatitis B, lifetime triple panel testing (HBsAg, anti-HBs, total anti-HBc) for individuals 18+ may be reimbursable once per lifetime.

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ModifiedBlue Cross Blue Shield - New MexicoPolicy CPCPLABO1S

Hepatitis Testing

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Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyHepatitis Testing

Policy CodePolicy CPCPLABO1S

Change TypeMaterial updates to coverage, frequency, and coding

Effective DateJul 25, 2025

Last ReviewJul 25, 2025

Next Review Date

Key ActionReview product-specific Plan documents and verify prior authorization requirements and coding before submitting claims for the added test codes.

SourceLink

POLICY UPDATE CHANGES

Antibody testing for HCV once every three months may be reimbursable for individuals with ongoing risk factors such as receiving immunosuppressant therapy.

Qualitative nucleic acid testing for HCV may be reimbursable in specified situations; age range for one-time screening of perinatally exposed infants changed from 2-17 to 2-6 months.

New language specifying reimbursable testing for hepatitis A and hepatitis D and stating quantitative viral load testing for HAV and HDV is not reimbursable.

Added codes 86692, 86708, 86709, 87380, 87523, 87516, 87799 to the policy.

Under Hepatitis B, lifetime triple panel testing (HBsAg, anti-HBs, total anti-HBc) for individuals 18+ may be reimbursable once per lifetime.

lifetimeHBV triple panel once per lifetime for adults ≥18

onceHCV antibody testing for adults ≥18

3 moHCV antibody testing interval for ongoing risk

CAP/CLIALab certification referenced

7New/added CPT/HCPCS codes

HAV/HDVViral load testing not reimbursable

Coverage Criteria for Hepatitis Testing

Hepatitis B - Initial and annual screening

Covered when specified criteria are met

HBV lifetime adult screening: For all individuals 18 years of age and older, triple panel testing (HBsAg, anti-HBs, total anti-HBc) once per lifetime may be reimbursable.age >= 18

[[chunk 3]]

Annual HBV screening for asymptomatic, non-pregnant individuals: Triple panel testing (HBsAg, anti-HBs, anti-HBc) annually for asymptomatic, non-pregnant individuals when any one of the following high-risk situations is met: infant born to an HBsAg-positive individual; born in or recently traveled to a region with HBV prevalence >= 2%; U.S.-born individuals not vaccinated as infants whose parents were born in regions with HBV prevalence >= 2%; individuals infected with HIV; individuals with a history of incarceration; individuals with a history of sexually transmitted infections or multiple sex partners; men who have sex with men; injection-drug users; household/needle-sharing contacts and sex partners of HBV-infected individuals; individuals with active or history of HCV infection; individuals on long-term hemodialysis; individuals with elevated liver enzymes; individuals with diabetes; healthcare and public safety workers exposed to blood or body fluids; individuals receiving immunosuppressant therapy.high-risk condition present

[[chunk 3]]

Hepatitis B - Follow-up testing

Covered follow-up tests in specific situations

IgM anti-HBc for anti-HBc positive: For individuals who test positive for anti-HBc, follow-up IgM anti-HBc testing to distinguish acute versus chronic infection may be reimbursable.

[[chunk 4]]

Anti-HBs for post-vaccination seroconversion: Anti-HBs testing for confirmation of seroconversion after hepatitis B vaccination may be reimbursable.

[[chunk 4]]

HBV DNA before immunosuppressive therapy: For individuals who test positive for HBV by initial antibody screening and who will undergo immunosuppressive therapy, HBV DNA testing may be reimbursable.

[[chunk 4]]

Hepatitis C - Screening, diagnostic, and monitoring tests

Covered when specified criteria are met

HCV lifetime antibody screening: For all individuals 18 years of age and older, antibody testing for HCV infection once per lifetime may be reimbursable.age >= 18

[[chunk 5]]

One-time post-exposure or risk-based antibody testing: One-time, post-exposure or diagnostic antibody testing may be reimbursable for individuals with recognized conditions or exposures including illicit intranasal or injectable drug use; receipt of clotting factor concentrates produced before 1987; history of hemodialysis; evidence of liver disease or persistently abnormal ALT; HIV infection; organ transplant before July 1992; receipt of blood transfusion or blood component before July 1992; history of incarceration; healthcare/public safety workers after occupational exposures; unregulated tattoo exposure; children born to HCV-positive individuals; and current sexual partners of HCV-infected persons.

[[chunk 5]]

Repeat HCV antibody testing for ongoing risk: Antibody testing for HCV once every three months may be reimbursable for individuals with ongoing risk factors while risk factors persist (ongoing hemodialysis; current injection drug use with sharing; engaging in high-risk sexual behavior).

Hepatitis A

Covered when specified criteria are met

Acute HAV testing: For individuals with signs and symptoms of acute viral hepatitis who have tested negative for HBV and HCV, testing for IgM anti-hepatitis A (HAV) or qualitative HAV RNA testing may be reimbursable.

[[chunk 7]]

Not covered: quantitative HAV viral load: Quantitative nucleic acid testing for HAV viral load is not reimbursable.

[[chunk 7]]

Hepatitis D

Covered when specified criteria are met

HDV testing for HBV-positive individuals: For individuals who have tested positive for HBV, testing for hepatitis D virus (anti-HDV) or qualitative HDV RNA testing may be reimbursable.

[[chunk 8]]

Not covered: quantitative HDV viral load: Quantitative nucleic acid testing for HDV viral load is not reimbursable.

[[chunk 8]]

Reimbursable Hepatitis Testing Criteria

Covered when conditions described in the reimbursement information are met (summarized from policy updates):

HBV initial screening: For all individuals 18 years of age and older, triple panel testing (HBsAg, anti-HBs, total anti-HBc) once per lifetime may be reimbursable.once per lifetime

applies to adults 18+

HCV antibody screening and follow-up: Antibody screening is the specified initial HCV screen; nucleic acid testing for HCV (including qualitative NAT) may be reimbursable as follow-up to a positive antibody screen to distinguish active from resolved infection.N/A

Includes qualitative NAT per 01/15/2025 update

Perinatally exposed infant HCV testing: One-time nucleic acid testing for perinatally exposed infants is reimbursable for infants aged 2-6 months.age 2-6 months

The policy explicitly states that quantitative nucleic acid testing for HAV viral load is not reimbursable. For individuals with signs and symptoms of acute viral hepatitis who have tested negative for HBV and HCV, only IgM anti-HAV or qualitative HAV RNA testing may be reimbursable; quantitative HAV viral load testing is excluded from reimbursement.

Updated reimbursement language reiterates that new hepatitis A and D provisions were added to the policy and that quantitative nucleic acid testing for HAV and HDV viral load is not reimbursable. The update clarifies allowable testing for HAV (IgM or qualitative RNA) and for HDV (anti-HDV or qualitative RNA) while disallowing quantitative viral load testing for these viruses.

Per the policy's not-covered designation, quantitative viral load testing for HAV and HDV is not reimbursable and is considered not covered. Providers should therefore not expect reimbursement for claims billed with quantitative HAV or HDV viral load assays.

Covered Indications

Screening, diagnostic, and monitoring of hepatitis A, B, C, and D

Screening, diagnostic, and monitoring of hepatitis A, B, C, and D according to risk factors, exposures, clinical signs, treatment initiation and monitoring (e.g., DAA therapy), and perinatal exposure.

HBV screening and lifetime panel: Triple panel testing (HBsAg, anti-HBs, total anti-HBc) for adults 18+; lifetime one-time testing may be reimbursable; annual screening with triple panel may be reimbursable for asymptomatic, non-pregnant individuals meeting specified high-risk criteria.age >=18; once per lifetime

[[chunk 3]]

HCV screening, confirmatory and monitoring tests: Initial antibody testing for HCV is the recommended screen; qualitative HCV RNA (NAT) is reimbursable as follow-up to a positive antibody to distinguish active vs resolved infection, for perinatally exposed infants (2-6 months), and for immunocompromised individuals. Quantitative HCV RNA testing and genotype testing are reimbursable in relation to DAA therapy (pre-initiation, during therapy, end of treatment, and at 12, 24, 48 weeks post-treatment).

[[chunk 5]][[chunk 6]]

Frequency Limits and Testing Intervals

inv-29: HBV triple panel for adults 64 18 64 once per lifetime

TestHBV triple panel (HBsAg, anti-HBs, total anti-HBc)

PopulationAdults 18 years of age and older

FrequencyOnce per lifetime

inv-30: HCV antibody test for adults 64 18 64 once per lifetime

TestHCV antibody test

PopulationAdults 18 years of age and older

FrequencyOnce per lifetime

Procedure and Billing Codes

Procedure Codes (illustrative inclusion)mixed

The policy states that the procedure code list is not an all-encompassing code list; inclusion does not guarantee coverage or reimbursement.

Added test codesCPT

86692
86708
86709
87380
87523
87516
87799

inv-12: HBV prevalence 64 contextual key-value

UseApplies when determining need for HBV screening (see high-risk criteria)

Source notePolicy references CDC-defined HBsAg prevalence by region (Note 1)

inv-13: Perinatal infant HCV screening age window 64 2-6 months

Age window2-6 months

TestOne-time qualitative HCV nucleic acid testing for perinatally exposed infants

Policy changeAge window revised from 2-17 months to 2-6 months per policy update

Provider Actions and Billing Guidance

Note

Check product-specific reimbursement requirements

The Plan has implemented certain lab management reimbursement criteria. Not all requirements apply to each product — providers must review Plan documents for product applicability prior to submission.

Not all requirements apply to every product — verify member’s plan documents before submitting claims.
Providers are responsible for accurate claim submission and must provide additional documentation upon request.

Prior Authorization

Added lab test codes; verify PA requirements

Added lab test codes to the policy; providers should verify payer prior authorization requirements before ordering or billing these tests.

New/added codes include: 86692, 86708, 86709, 87380, 87523, 87516, 87799 (verify full code lists and descriptions in code tables).
Follow payer submission rules and confirm any prior authorization (PA) requirements for newly added codes.

Ordering and Submission Requirements

Prior Authorization

Review Plan documents and submit accurately coded claims

Providers must review Plan documents for product-specific reimbursement and submit claims with accurate coding and documentation; claims will be adjudicated per plan and contract terms.

Confirm product applicability and coverage in the member's Plan documents before ordering tests
Ensure coding and documentation match the service rendered

Note

Order HCV NAT only for covered indications and document the clinical reason

Nucleic acid testing for HCV may be performed as follow-up to a positive antibody screen and in specified clinical situations (including one-time infant screening and testing for immunocompromised individuals); the ordering clinician should document the indication.

Follow-up NAT to positive antibody test to differentiate active vs resolved infection
One-time NAT for perinatally exposed infants (age window revised to 2-6 months)
NAT may be reimbursable for immunocompromised individuals

Not Covered Services

Under the NOT COVERED section the policy states that quantitative nucleic acid testing for HAV and HDV viral load is not reimbursable. This is repeated in the policy update history, which added explicit language that quantitative viral load testing for both HAV and HDV will not be reimbursed and may be denied if billed.

The updated policy language reiterates the exclusion: quantitative nucleic acid testing for HAV and HDV viral load is not reimbursable. The change history documents the addition of this not-covered statement for hepatitis D alongside the hepatitis A language.

Background

This policy provides clinical testing coverage criteria for hepatitis A, B, C, and D, including recommended test types and contexts for reimbursement. It specifies screening and diagnostic approaches such as the HBV triple panel (HBsAg, anti-HBs, total anti-HBc) once per lifetime for adults ≥18, HCV antibody screening with follow-up qualitative or quantitative nucleic acid testing where indicated, perinatal infant testing windows, and that for acute hepatitis evaluation IgM anti-HAV or qualitative HAV RNA testing may be reimbursable. The policy also clarifies that qualitative HDV RNA or anti-HDV testing may be reimbursable for HBV-positive individuals, while quantitative HAV/HDV viral load testing is not reimbursable.

Definitions

inv-23: HBV triple panel 64 definition of HBsAg, anti-HBs, total anti-HBc

HBsAgHepatitis B surface antigen — indicates current HBV infection (part of triple panel)

anti-HBsHepatitis B surface antibody — indicates immunity from vaccination or recovery from infection

total anti-HBcTotal antibody to hepatitis B core antigen — indicates prior or current HBV exposure

inv-24: HCV testing 64 definition and testing algorithm (antibody followed by NAT)

Initial algorithmHCV antibody testing is the specified initial screen; positive antibody results may be followed by nucleic acid testing to differentiate active vs resolved infection

Nucleic acid testingQualitative NAT (HCV RNA) may be used as follow-up to a positive antibody test and in specified situations (perinatal screening, immunocompromised individuals)

Revision History

2025-07-25effective_dateLatest

Policy effective date with reimbursement updates including added frequency guidance for immunosuppressed individuals and additions to reimbursement items for HAV and HDV; added CPT/HCPCS codes.

2025-01-15revision

Revised reimbursement language to specify 'qualitative' nucleic acid testing for HCV and narrowed the perinatally exposed infant screening window to 2-6 months; added language for hepatitis A and D testing and non-reimbursement of quantitative HAV/HDV viral load.

2024-03-15

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyHepatitis Testing

Policy CodePolicy CPCPLABO1S

Change TypeMaterial updates to coverage, frequency, and coding

Effective DateJul 25, 2025

Last ReviewJul 25, 2025

Next Review Date

Key ActionReview product-specific Plan documents and verify prior authorization requirements and coding before submitting claims for the added test codes.

SourceLink

On This Page

Qualitative HCV RNA testing: Qualitative nucleic acid testing for HCV may be reimbursable as follow-up to a positive antibody test to differentiate active versus resolved infection; for one-time screening of perinatally exposed infants aged 2-6 months; and for individuals who are immunocompromised.

[[chunk 6]]

HCV genotype and quantitative RNA testing related to DAA therapy: One-time HCV genotype testing prior to DAA initiation may be reimbursable; quantitative HCV RNA testing may be reimbursable prior to initiation of DAA therapy, after 4 weeks of therapy, at the end of treatment, and at 12, 24, and 48 weeks after completion of treatment.

[[chunk 6]]

age window revised from 2-17 to 2-6 months

Immunocompromised and high-risk repeat testing: For individuals receiving immunosuppressant therapy or who are immunocompromised or have ongoing risk factors, antibody testing for HCV once every three months may be reimbursable while risk factors persist.every 3 months while risk persists

added frequency for immunosuppressed individuals

HAV/HDV testing: For individuals with signs and symptoms of acute viral hepatitis who test negative for HBV and HCV, IgM anti-HAV or qualitative HAV RNA may be reimbursable; for individuals who test positive for HBV, anti-HDV or qualitative HDV RNA may be reimbursable. Quantitative nucleic acid testing for HAV and HDV viral load is not reimbursable.N/A

policy explicitly disallows quantitative HAV/HDV viral load reimbursement

Acute HAV evaluation: For symptomatic individuals who are HBV- and HCV-negative, IgM anti-HAV or qualitative HAV RNA testing may be reimbursable; quantitative HAV viral load testing is not reimbursable.

HDV testing linked to HBV positivity: For individuals positive for HBV, anti-HDV or qualitative HDV RNA testing may be reimbursable; quantitative HDV viral load testing is not reimbursable.

[[chunk 8]]

Initial, follow-up, perinatal, symptomatic, and immunocompromised testing

Initial screening, follow-up for positive antibody tests, perinatal exposure screening, symptomatic acute hepatitis evaluation, and testing for immunocompromised individuals.

Initial HCV antibody screening: Antibody screening for HCV is the initial recommended test for adults; follow-up nucleic acid testing (qualitative NAT) is reimbursable to differentiate active versus resolved infection when antibody is positive.

[[chunk 21]][[chunk 20]]

Perinatal HCV testing: One-time qualitative nucleic acid testing for perinatally exposed infants aged 2-6 months may be reimbursable.age 2-6 months

[[chunk 6]][[chunk 20]]

Acute symptomatic evaluation: For individuals presenting with signs or symptoms of acute viral hepatitis who are negative for HBV and HCV, IgM anti-HAV or qualitative HAV RNA testing may be reimbursable.

[[chunk 7]]

Testing for immunocompromised individuals: Qualitative nucleic acid testing for HCV and appropriate viral testing for HAV/HDV may be reimbursable for immunocompromised individuals; ordering clinician should document indication.

[[chunk 6]][[chunk 8]]

Repeat testing for individuals with ongoing risk or immunosuppression: For individuals receiving immunosuppressant therapy or with ongoing risk factors, repeat antibody testing for HCV once every three months may be reimbursable while risk factors persist.every 3 months while risk persists

[[chunk 20]]

inv-31: HCV antibody test for ongoing risk factors 64 every 3 months while risk persists

TestHCV antibody test

PopulationIndividuals with ongoing risk factors (e.g., ongoing hemodialysis; current injection drug use with sharing; high-risk sexual behavior)

FrequencyEvery 3 months while risk factors persist

inv-32: HBV triple panel (HBsAg, anti-HBs, total anti-HBc) for adults 18+ 64 Once per lifetime (updated language)

TestHBV triple panel (HBsAg, anti-HBs, total anti-HBc)

PopulationAdults 18 years of age and older

FrequencyOnce per lifetime

inv-33: HCV antibody testing for individuals receiving immunosuppressant therapy or with ongoing risk factors 64 Every 3 months while risk factors persist

TestHCV antibody testing

PopulationIndividuals receiving immunosuppressant therapy or with ongoing risk factors

FrequencyEvery 3 months while risk factors persist

inv-34: Nucleic acid testing for perinatally exposed infants aged 2-6 months 64 One-time

TestQualitative nucleic acid testing (HCV RNA)

PopulationPerinatally exposed infants aged 2-6 months

FrequencyOne-time

Documentation Required

Documentation should support indication for testing

Documentation should clearly support the clinical indication for testing. For example, documentation must justify one-time lifetime HBV triple panel testing for adults or provide risk-factor evidence to support repeat HBV testing.

For HBV triple panel (HBsAg, anti-HBs, anti-HBc): indicate if this is the one-time lifetime screen or provide clinical justification for repeat testing (e.g., ongoing risk factors).
Providers are responsible for submission of accurate documentation and for furnishing additional records upon request to substantiate medical necessity.

Billing Rule

Nucleic acid testing for HCV — ordering and billing guidance

Nucleic acid testing for HCV is reimbursable in specific situations: as follow-up to a positive HCV antibody screen to differentiate active from resolved infection, and for one-time screening of perinatally exposed infants in the specified age window.

Nucleic acid testing (qualitative or quantitative as specified) may be reimbursable as follow-up after a positive HCV antibody test.
One-time screening for perinatally exposed infants is reimbursable for the age range specified in plan guidance (verify current age window in plan documents).
Providers should order the appropriate HCV NAAT (qualitative vs quantitative) per the policy criteria and document indications on the claim.

Quantitative testingQuantitative HCV RNA testing (viral load) is used for monitoring around DAA therapy (pre-initiation, 4 weeks on therapy, end of treatment, and 12/24/48 weeks post-treatment)

inv-25: HBV triple panel 64 alternate chunk definition for the triple panel

DefinitionHBV triple panel includes HBsAg, anti-HBs, and total anti-HBc

PurposeUsed for initial lifetime screening and to determine immune status or past exposure

Population noteRecommended for adults 18+ as a once-per-lifetime screen unless high-risk conditions warrant repeat testing

inv-26: Qualitative nucleic acid testing 64 definition and use cases

DefinitionQualitative nucleic acid testing detects presence or absence of viral RNA (e.g., HCV, HAV, HDV) and is used to confirm active infection in specific clinical situations

Use casesFollow-up to a positive HCV antibody test, one-time perinatal infant screening (2-6 months), and testing immunocompromised individuals

Policy limitationQuantitative viral load testing for HAV and HDV is not reimbursable (qualitative NAT may be reimbursable where specified)

Updated reimbursement information (revision to HCV follow-up language) per literature review.