Folate Testing
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Defines Blue Cross Blue Shield - New Mexico reimbursement rules for serum and red blood cell folate testing, and folate receptor autoantibody testing; applies to providers submitting claims to BCBSNM.
No material clinical or coverage changes in this revision.
Coverage Criteria for Folate Testing
Coverage criteria for folate testing
Measurement of serum folate concentration may be reimbursable when one of the following clinical indications is met. Other folate-related tests are restricted as noted.
ANY of the following
- Megaloblastic or macrocytic anemia: Measurement of serum folate concentration for individuals with megaloblastic anemia or macrocytic anemia is reimbursable.
- Bariatric procedures: Measurement of serum folate concentration for individuals who have undergone, or who are scheduled for, bariatric procedures such as Roux-en-Y gastric bypass, sleeve gastrectomy, or biliopancreatic diversion/duodenal switch is reimbursable.
Specific Covered Indications
Megaloblastic or macrocytic anemia
Serum folate measurement may be reimbursable when the following condition is present.
Pre- or post-bariatric surgery
Serum folate measurement may be reimbursable when the following condition is present.
Tests and Indications Not Reimbursable
Measurement of red blood cell (RBC) folate is explicitly excluded from reimbursement under this policy. The policy states: "For all indications, measurement of red blood cell (RBC) folate is not reimbursable." Providers should not submit claims for RBC folate testing for any indication.
Testing for folate receptor autoantibodies is not reimbursable under this policy. The document specifies: "For all situations, folate receptor autoantibody testing is not reimbursable." Claims for this test should not be submitted for reimbursement.
Measurement of serum folate is reimbursable only for the specified clinical indications: megaloblastic or macrocytic anemia, or when the individual has undergone or is scheduled for certain bariatric procedures (e.g., Roux-en-Y gastric bypass, sleeve gastrectomy, biliopancreatic diversion/duodenal switch). The policy states: "For all indications not described above, measurement of serum folate concentration is not reimbursable." Providers should limit serum folate testing to the covered indications when seeking reimbursement.
Example Procedure Codes
Documentation and Claims Submission
Documentation and claims submission requirements
Providers are responsible for submitting accurate documentation of services performed and must submit claims using valid code combinations from HIPAA-approved code sets. Claims must be coded according to industry standard coding guidelines (for example: Uniform Billing Editor, AMA CPT Assistant, HCPCS, ICD-10-CM/PCS, NDCs, DRG guidelines, CMS NCCI Policy Manual and CCI edits). Claims are subject to code edit protocols and may be reviewed; providers may be asked to submit additional documentation upon request.
- Use valid code combinations from HIPAA-approved code sets.
- Code claims per industry coding guidance (CPT, HCPCS, ICD-10, NCCI/CCI, etc.).
- Expect code-edit protocols and claim review; provide additional documentation if requested.
Ordering and Submission Requirements
Ordering and plan-specific review
Providers must review plan documents for product-specific applicability and submit accurate documentation and appropriate coding when ordering folate testing. The policy notes that not all lab management reimbursement requirements apply to each product, so providers should confirm eligible coverage in Plan documents.
- Review member Plan documents (Certificates, Benefit Booklets, Summary Plan Descriptions) for coverage determinations.
- Ensure orders and claims reflect accurate coding and documentation consistent with the Plan's reimbursement criteria.
Policy Scope and Definitions
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