CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLAB014

Prenatal Screening (Nongenetic) Laboratory Testing

Defines BCBSNM reimbursement stance and criteria for routine nongenetic prenatal laboratory screening tests for pregnant individuals across applicable products; providers should check plan documents for specific coverage.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPrenatal Screening (Nongenetic) Laboratory Testing

Policy CodePolicy CPCPLAB014

Change TypeRevisedremoved codesclarified exclusions

Effective DateJan 15, 2025

Next Review Date

Key ActionSubmit accurate documentation and code claims using valid HIPAA-approved code sets; claims may be reviewed and additional documentation requested.

SourceLink

POLICY UPDATE CHANGES

Updated recommended testing type for HIV, hepatitis B, and hepatitis C; edited wording for Neisseria gonorrhoeae and Group B streptococcal screening, and clarified FFN coverage to ambulatory setting for singleton or twin pregnancies with signs or symptoms of preterm labor.

Removed reference to CPCPLAB022 Prenatal Screening for Fetal Aneuploidy (archived) and removed several procedure codes (83020, 83021, 85048, 86701, 86702, 86703, G0432, G0433, G0435, 0167U).

Clarified that hCG testing is not reimbursable for normal uncomplicated pregnancy and removed redundant prior statement about FFN coverage.

15+distinct prenatal screening tests or test groups enumerated as potentially reimbursable

4high-risk criteria for third-trimester rescreening

FFN ambulatory

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Reimbursable Prenatal Screening Criteria

Reimbursable prenatal screening criteria

Reimbursable routine prenatal screening and specific condition-based coverage:

ALL of the following

Routine prenatal screening tests (may be reimbursable)
- Antigen/antibody combination assay screening for HIV infection
- Screening for Chlamydia trachomatis infection
- Screening for Neisseria gonorrhoeae infection
- Triple panel screening for hepatitis B (HBsAg, anti-HBs, total anti-HBc)
- Screening for syphilis
- Antibody screening for hepatitis C
- Screening for type 2 diabetes at the first prenatal visit
- Screening for gestational diabetes during gestational weeks 24-28 and at the first prenatal visit if risk factors are present
- Determination of blood type, Rh(D) status, and antibody status at first prenatal visit; repeat Rh(D) antibody testing at 24-28 weeks for unsensitized Rh(D)-negative individuals unless biological father is known Rh(D)-negative
- Anemia screening (CBC or hemoglobin and hematocrit with mean corpuscular volume)
- Group B streptococcal screening once per pregnancy (recommended during gestational weeks 36-37)
- Urinalysis and urine culture
- Rubella antibody testing
- Varicella immunity testing
- Tuberculosis screening for pregnant individuals deemed to be at high risk for TB

Third-trimester rescreening when any high-risk criterion is met

Rescreening of Chlamydia trachomatis, Neisseria gonorrhoeae, syphilis, and/or HIV may be reimbursable for individuals under 25 years of age
Rescreening may be reimbursable for individuals with new or multiple sexual partners
Rescreening may be reimbursable for individuals with a history of sexually transmitted infections
Rescreening may be reimbursable for individuals with past or current injection drug use

Condition-based and non-reimbursable testing

Rapid HIV testing may be reimbursable for pregnant individuals who present in active labor with an undocumented HIV status
For individuals pregnant with singleton or twin pregnancies presenting in the ambulatory setting with signs and symptoms of preterm labor, fetal fibronectin (FFN) assays may be reimbursable
Human chorionic gonadotropin (hCG) hormone testing is not reimbursable for individuals with a normal pregnancy without complications
Serial monitoring of salivary estriol levels for preterm labor risk assessment is not reimbursable

Procedure Codes and Timing Guidance

Procedure code updatesCPT

87389	Newly added code referenced in update history
83020	Removed per update history
83021	Removed per update history
85048	Removed per update history
86701	Removed per update history
86702	Removed per update history
86703	Removed per update history
G0432	Removed per update history
G0433	Removed per update history
G0435	Removed per update history

1–10 of 11

1/2

Neutral / informationalmixed

(See full policy note)

The inclusion of a code does not guarantee it is a covered service or eligible for reimbursement; this is not an all-encompassing list.

Gestational window for GBS screening (inv-03)

Recommended gestational windowGroup B streptococcal (GBS) screening is recommended during gestational weeks 36–37

FrequencyScreening once per pregnancy

Related test typeCulture-based or NAAT testing as specified by provider clinical practice (document lists Group B streptococcal screening)

Gestational window for gestational diabetes screening (inv-04)

Primary gestational windowGestational diabetes screening is reimbursable during gestational weeks 24–28

Early screeningScreening at the first prenatal visit is indicated and may be reimbursable if risk factors for preexisting diabetes are present

Claims Submission, Documentation, and Condition-Based Reimbursement Notes

Documentation Required

Claims submission and documentation

Providers are responsible for submission of accurate documentation of services performed. Submit claims using valid HIPAA-approved code sets and appropriate industry-standard coding guidelines (e.g., Uniform Billing, AMA CPT, 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 claim review against benefit terms, provider contract language, medical policies, clinical payment and coding policies, and coding software logic. Upon request, providers should supply additional documentation to support medical necessity and coding.

Bill using valid HIPAA-approved code sets and industry coding guidance
Claims subject to code edit protocols and claim review
Provide additional documentation upon request

Key Terms and Listed Routine Tests

Individuals who are pregnant — terminology note (inv-07)

TerminologyPolicy text refers to pregnant persons as 'pregnant individuals' rather than 'women'

Scope noteCoverage language and criteria apply to 'pregnant individuals' across applicable products; providers should consult plan documents for product-specific rules

Documentation guidanceUse of inclusive terminology in clinical documentation and claims should reflect the policy language where appropriate

Laboratory tests listed in Reimbursement Information item 1 (inv-08)

Core routine prenatal screenings (selected)Antigen/antibody combination assay for HIV; Chlamydia trachomatis; Neisseria gonorrhoeae; syphilis; hepatitis B triple panel (HBsAg, anti-HBs, total anti-HBc); hepatitis C antibody;

Metabolic and hematology tests

Certain prenatal and condition-specific tests are reimbursable only when clinical criteria are met. Reimbursement examples include rapid HIV testing for pregnant individuals presenting in active labor with undocumented HIV status, fetal fibronectin (FFN) assays for symptomatic preterm labor in singleton or twin pregnancies in the ambulatory setting, and third‑trimester re‑screening for chlamydia, gonorrhea, syphilis, and/or HIV when high‑risk criteria are present (age <25, new/multiple partners, history of STIs, or past/current injection drug use). Routine prenatal screenings (e.g., HIV antigen/antibody assay, chlamydia, gonorrhea, hepatitis B panel, syphilis, hepatitis C antibody, diabetes screening at first visit, GDM screening at 24–28 weeks or earlier with risk factors, blood type/Rh/antibody testing including repeat Rh antibody at 24–28 weeks for unsensitized Rh‑negative women, CBC/hemoglobin/hematocrit, Group B strep screening at 36–37 weeks, urinalysis/urine culture, rubella and varicella immunity testing, and TB screening when high risk) are generally reimbursable per policy. hCG testing for an uncomplicated normal pregnancy and serial salivary estriol monitoring for preterm labor risk assessment are not reimbursable.