CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLAB0065

Human Immunodeficiency Virus (HIV) — Laboratory Testing Reimbursement

Defines Blue Cross Blue Shield of New Mexico reimbursement criteria for HIV-related laboratory tests (screening, nucleic acid testing, viral load quantification, genotyping/phenotyping) and who may be reimbursed under plan-specific coverage.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyHuman Immunodeficiency Virus (HIV) — Laboratory Testing Reimbursement

Policy CodePolicy CPCPLAB0065

Change TypeMaterial updates to screening and testing frequency and added nucleic acid testing criteria

Effective DateAug 8, 2025

Next Review DateN/A

Key ActionProviders must submit accurate documentation and may be asked to provide additional documentation upon request; claims are subject to plan documents and coding rules.

SourceLink

POLICY UPDATE CHANGES

Added 'with an antigen/antibody combination assay' to initial screening reimbursement statement.

Changed repeat screening frequency language to 'no more than one test every 90 days' for individuals 11 to 65.

Added reimbursement criteria allowing nucleic acid testing (qualitative or quantitative) for HIV-1 and HIV-2 (no more than one test every month) in specific situations.

Added '(no more than one test every month)' to plasma HIV RNA quantification monitoring criteria.

1.0policy version

04/28/2025approval date

08/08/2025plan effective date

~24listed codes

HIV Test Reimbursement Criteria

HIV test reimbursement criteria

Reimbursement criteria by test type and patient situation:

ALL of the following

Initial HIV screening with an antigen/antibody combination assay may be reimbursable for individuals aged 11-65.
Repeat antigen/antibody screening for individuals aged 11-65 may be reimbursable (no more than one test every 90 days).
Annual screening for high-risk individuals: Annual screening may be reimbursable for individuals considered at high risk, including: MSM; injection drug users; individuals with multiple sex partners; individuals who have sex for drugs or money; individuals who have sex with someone who is HIV-positive or has other STIs; having sex without the use of a condom.

ALL of the following

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyHuman Immunodeficiency Virus (HIV) — Laboratory Testing Reimbursement

Policy CodePolicy CPCPLAB0065

Change TypeMaterial updates to screening and testing frequency and added nucleic acid testing criteria

Effective DateAug 8, 2025

Next Review DateN/A

Key ActionProviders must submit accurate documentation and may be asked to provide additional documentation upon request; claims are subject to plan documents and coding rules.

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.

ALL of the following

When genotyping or phenotyping may be reimbursable
- Prior to initiating doravirine therapy (genotyping and phenotyping is required).
- For individuals who have failed a course of antiviral therapy.
- For individuals who have suboptimal viral load reduction.
- For individuals who have been noncompliant with therapy.
- To guide treatment decisions in individuals with acute or recent infection (within the last 6 months).
- For antiretroviral-naïve individuals entering treatment.
- For HIV-infected pregnant individuals in the following situations: before initiation of antiretroviral therapy; and for those with detectable HIV RNA loads.
- For treatment-experienced individuals on failing regimens thought to have multidrug resistance, HIV phenotyping may be reimbursable.

Procedure and Billing Codes / Intervals

Listed procedure and test codesmixed

86689
86701
86702
86703
87389
87390
87391
87534
87535
87536

1–10 of 25

1/3

Repeat screening interval — Antigen/antibody screening

Repeat screening intervalNo more than one antigen/antibody screening test every 90 days for individuals aged 11–65 when repeated.

Applies toIndividuals 11 to 65 years of age.

ContextThis limit refers to repeat antigen/antibody screening tests following initial screening.

Nucleic acid / viral load interval — Monthly limit

Nucleic acid / plasma HIV RNA intervalNo more than one nucleic acid (qualitative or quantitative) or plasma HIV RNA test every month in specified situations.

Specified situationsWhen initial screening is positive or indeterminate, or when recent exposure is suspected or reported; also for monitoring disease progression, response to therapy, infants <18 months born to HIV-positive mothers, and predicting maternal-fetal transmission (plasma RNA).

Test typesQualitative or quantitative nucleic acid testing for HIV-1 and HIV-2; plasma quantification of HIV-1 or HIV-2 RNA.

Documentation, Claims, and Frequency Limits

Documentation Required

Documentation, coding, and claim review — submit accurate records and respond to requests

Providers must submit accurate documentation of services performed, code claims using valid HIPAA-approved code sets and industry-standard coding guidelines, and be prepared to provide additional documentation upon request. Claims are subject to code edit protocols and review against plan documents, provider contracts, medical policies, CPCPs, and coding software logic.

Submit accurate documentation of services performed and use valid HIPAA-approved code combinations.
Code claims according to industry standard coding guidelines (e.g., UB, CPT, HCPCS, ICD-10-CM/PCS, NDC, DRG, CMS NCCI).
Claims are subject to code edit protocols and may be reviewed against benefit coverage, provider contract language, medical policies, CPCPs, and coding software logic.
Provide additional documentation upon request.

Billing Rule

Frequency limits for screening, nucleic acid testing, and viral load monitoring

Frequency limits apply to HIV testing: antigen/antibody screening may be reimbursed no more than once every 90 days when repeated for individuals 11–65, and nucleic acid testing and plasma HIV RNA quantification are limited to no more than one test every month in the specified clinical situations.

Antigen/antibody combination screening: initial reimbursable for ages 11–65; repeat screening reimbursable no more than one test every 90 days.
Nucleic acid testing (qualitative or quantitative) for HIV-1 and HIV-2: reimbursable (no more than one test every month) when initial screening is positive or indeterminate, or recent exposure is suspected/reported.
Plasma quantification of HIV-1 or HIV-2 RNA: reimbursable (no more than one test every month) for monitoring disease progression, monitoring response to therapy, infants <18 months born to HIV-positive mothers, and predicting maternal-fetal transmission.

Plan Documents and High-Risk Individuals

Plan documents governing coverage

Plan documents govern conflictsCertificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents govern if they conflict with this policy.

Provider contracts governIf a conflict arises between this policy and a provider contract, the provider contract will govern.

DiscretionBCBSNM may use reasonable discretion in interpreting and applying this policy; the plan has final discretionary authority as provided under plan documents.

High-risk individuals

Definition of high-risk individualsMen who have sex with men (MSM); injection drug users; individuals with multiple sex partners; individuals who have sex for drugs or money; individuals who have sex with someone who is HIV-positive or has other STIs; having sex without the use of a condom.

Reimbursement implicationAnnual HIV screening may be reimbursable for individuals considered high risk.

Age scopeApplies within the policy’s screening criteria (e.g., initial and repeat screening statements for ages 11–65 where specified).