CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLABOO7

Preventive Screening in Adults

Reimbursement and lab management criteria for preventive screening tests in adults, governing coverage and billing expectations for providers delivering these services to BCBSNM members.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPreventive Screening in Adults

Policy CodePolicy CPCPLABOO7

Change TypeNew policy

Effective DateJan 1, 2023

Next Review Date

Key ActionReview applicable Plan documents for product-specific prior authorization or coverage requirements before ordering screening tests.

SourceLink

POLICY UPDATE CHANGES

New policy implemented.

1New policy (1/1/2023)

11-65HIV screening age range

45-75Colorectal screening age

3 yrsDiabetes screening interval

3 yrsFIT-DNA interval

Coverage and Screening Criteria

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPreventive Screening in Adults

Policy CodePolicy CPCPLABOO7

Change TypeNew policy

Effective DateJan 1, 2023

Next Review Date

Key ActionReview applicable Plan documents for product-specific prior authorization or coverage requirements before ordering screening tests.

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.

Covered Screening Criteria

Reimbursement may be provided when the following population- and interval-specific criteria are met.

Hepatitis B screening: Annual screening for hepatitis B virus infection may be reimbursable in asymptomatic individuals at high risk. High-risk groups include: persons born in geographic regions with HBsAg prevalence >2%; U.S.-born persons not vaccinated as infants whose parents were born in regions with HBsAg prevalence >8%; injection-drug users; men who have sex with men; persons with elevated ALT/AST of unknown etiology; pregnant individuals; persons requiring cytotoxic or immunosuppressive therapy; infants born to HBsAg-positive mothers; healthcare and public safety workers exposed to blood or body fluids; household contacts and sex partners of HBV-infected persons; persons infected with HIV; persons with multiple sex partners; individuals sharing needles; and persons on long-term hemodialysis.annual for high-risk

See source for full enumerated list.

HIV screening: Screening for HIV infection may be reimbursable in adolescents and adults aged 11 to 65 years and in all pregnant individuals (including those who present in labor and are untested). Annual screening may be reimbursable for individuals at high risk, including men who have sex with men, injection drug users, individuals who exchange sex for drugs or money, persons with multiple sex partners, persons who have sex with someone known to be HIV-positive or with other STIs, and those who have condomless sex.annual for high-risk

See source for examples of high-risk behaviors.

Type 2 diabetes screening: Screening for type 2 diabetes mellitus with fasting plasma glucose, oral glucose tolerance test, or hemoglobin A1c may be reimbursable once every three years for asymptomatic individuals aged 35 to 70 years who are overweight or obese (BMI ≥25, or ≥23 for Asian Americans). Individuals with family history of diabetes, prior gestational diabetes, or polycystic ovarian syndrome, and those from certain ethnic groups (African American, American Indian/Alaska Native, Asian American, Hispanic/Latino, Native Hawaiian/Pacific Islander) are eligible. For individuals with a history of gestational diabetes who are not currently pregnant and not previously diagnosed with type 2 diabetes, screening is recommended within the first year postpartum with specified follow-up and rescreening intervals as described in the source.once every 3 years; BMI thresholds as stated

See source for postpartum rescreening guidance.

Colorectal cancer screening: Screening for colorectal cancer may be reimbursable in asymptomatic individuals aged 45 to 75 years using accepted modalities and intervals: stool-based tests (gFOBT annually or FIT annually); stool DNA testing (FIT-DNA/Cologuard once every 3 years); direct visualization tests (colonoscopy every 10 years; CT colonography every 5 years; flexible sigmoidoscopy every 5 years; or flexible sigmoidoscopy every 10 years combined with annual FIT).age 45-75; intervals vary by modality

See source for modality-specific intervals.

Screening for colorectal cancer in asymptomatic, average-risk individuals older than 75 years is not reimbursable. Screening of asymptomatic, non-pregnant individuals for anemia and for thyroid disease is also listed as not reimbursable. These age-based and asymptomatic exclusions apply to routine screening indications and do not address diagnostic testing for symptoms or investigation of abnormal findings.

The policy explicitly lists several tests and techniques that are not reimbursable when used for routine screening: screening for anal HPV infection; screening for anal cytological abnormalities (anal Pap); screening for Herpes Simplex Virus (HSV) infection in asymptomatic individuals; and use of culture for detection of Chlamydia. Additionally, certain colorectal screening techniques and intervals are defined elsewhere, with FIT-DNA (Cologuard) noted as reimbursable every 3 years while the listed anal and HSV screening methods remain excluded for asymptomatic screening.

Provider Responsibilities and Prior Authorization

Prior Authorization

Product-specific coverage / prior authorization

Some products require prior authorization or have product-specific coverage rules. Review the member's plan documents and benefit materials to determine whether prior authorization or other product-specific requirements apply before ordering laboratory services.

Review the member's specific plan documents (Certificates of Benefits, benefit booklets, Summary Plan Descriptions) for product-specific prior authorization and coverage applicability.
Check for product exclusions, benefit limits, or medical management programs that may affect reimbursement prior to performing services.

Documentation Required

Provider documentation responsibility

Providers must submit accurate, complete documentation supporting billed services. BCBSNM may request additional records to substantiate medical necessity and coding. Failure to provide requested documentation may result in claim denial or recoupment.

Maintain and furnish complete medical records, test orders, and relevant clinical information when requested.
Ensure claims include appropriate diagnosis and procedure codes consistent with submitted documentation.

Denial Risk

Documentation and coding review may trigger denial

Claims are subject to coding and documentation review against coverage, contract, policy, and code-edit logic. Reviews may identify coding errors, inappropriate code combinations, or noncovered services; such findings can lead to claim denial or payment adjustment.

Claims may be denied or adjusted when code edits, NCCI/CCI logic, or medical policy determinations indicate services are not payable.
Ensure coding follows industry standards (CPT, HCPCS, ICD-10, NDC, DRG) and review NCCI/CCI edits prior to submission.

Note

Provider responsibilities — action highlight

This section highlights provider actions to reduce claim denials and delays: verify product-specific requirements, submit accurate documentation, and code according to accepted standards. When in doubt, consult the member's plan documents or provider contract.

Confirm prior authorization and benefit applicability before performing services.
Provide complete supporting documentation when requested to avoid denials.
Adhere to standard coding guidelines and review claim-edit feedback.

Definitions and High-risk Populations

High-risk populations — targeted screening populations

Persons from regions with HBsAg prevalence >2%Individuals born in geographic regions with HBsAg prevalence of >2 percent (U.S.-born persons not vaccinated as infants whose parents were born in regions with >8% prevalence are specifically included)

Injection-drug usersIndividuals who use injection drugs or share needles

Men who have sex with men (MSM)Men who have sex with men are listed as a high-risk group for HBV and HIV screening

Pregnant individualsAll pregnant individuals are included for Hepatitis B and HIV screening (including those presenting in labor who are untested)

Persons with elevated liver enzymesPersons with elevated ALT/AST of unknown etiology are included for hepatitis B screening

Healthcare/public safety workers and household contactsHealthcare and public safety workers exposed to blood/body fluids, household contacts, and sex partners of HBV-infected persons are specified high-risk groups

Most actionable: Annual HIV screening for high-risk individualsAnnual HIV screening may be reimbursable for individuals at high risk (MSM, injection drug users, transactional sex, multiple sex partners, sex with known HIV-positive persons, or condomless sex)

81528
82270
82274
82947
82950
82951
82952
83540
84443
86689

81528
82270
82274
82947
82950
82951
82952
83540
84443
86689

OpenPayer

Preventive Screening in Adults

Coverage and Screening Criteria

Listed Codes and Billing

Provider Responsibilities and Prior Authorization

Background and Policy Scope

Definitions and High-risk Populations