Find policies, billing codes, payers, states, and providers
Pediatric Preventive Screening
Customize your policy alerts
Sign up for Blue Cross Blue Shield - New Mexico Policy RPLAB016 alerts
Get alerted when Policy RPLAB016 changes without checking for updates manually.
Monitor payer policy activity
Defines BCBSNM reimbursement criteria for laboratory-based preventive screening tests for individuals from newborn through age 18 (excluding newborn genetic disorder screening); applies to claims submitted to Blue Cross Blue Shield of New Mexico.
No material clinical or coverage changes in this revision.
Pediatric Preventive Screening Coverage Criteria
Pediatric preventive screening coverage criteria
Covered when ALL of the following age-, test-, and risk-specific conditions are met:
Newborn screens
- Newborn metabolic/genetic screening may be reimbursable when it follows all applicable federal and state law recommendations.
- Screening for hyperbilirubinemia in all newborns may be reimbursable.
- Screening for congenital hypothyroidism in all newborns using serum T4 and/or TSH may be reimbursable.
- Screening for sickle cell disease in all newborns may be reimbursable.
Lead screening (children at increased risk)
- Lead exposure risk must be present (see defined risk factors).
ANY of the following
- One blood lead test at 6 months of age.
- One blood lead test at 9 months of age.
- One blood lead test at 12 months of age.
- One blood lead test per year from 2 years through 6 years of age.
Anemia (hemoglobin/hematocrit)
ANY of the following
- Hemoglobin/hematocrit screening for all individuals at 12 months of age.
- Hemoglobin/hematocrit screening for individuals ≥4 months of age who are at increased risk for iron deficiency (see defined risk factors).
Tuberculosis screening
- Individual is ≥1 month of age.
- Individual is at increased risk of contracting tuberculosis (see defined risk factors).
Dyslipidemia screening
- Screening may be performed with a fasting lipid profile or a non-fasting non-HDL-C.
ANY of the following
- Annual screening for children and adolescents at increased risk due to personal or family history (see defined risk factors).
- One screening for all children/adolescents during each specified age period: once between 9 and 11 years of age and once at 17 years of age.
Procedure Codes and Screening Schedules
Claims, Documentation, and Review Requirements
Claims documentation and review — submit accurate documentation and valid codes
Providers must submit accurate documentation of services rendered and use valid code combinations from HIPAA‑approved code sets; claims are subject to code edit protocols and may be reviewed. Upon request, providers should supply any additional documentation to support the claim.
- Submit claims using valid code combinations from HIPAA‑approved code sets (CPT, HCPCS, ICD‑10‑CM/PCS, NDC, DRG as applicable).
- Code claims according to industry standard coding guidelines (e.g., Uniform Billing Editor, AMA CPT Assistant, CMS NCCI policy manual and CCI table edits).
- Claims are subject to code edit protocols and claim review; provide additional documentation when requested.
Risk Factor Definitions and Newborn Screening
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.