CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLAB014

Prenatal Screening (Nongenetic)

Defines BCBSNM reimbursement criteria for routine nongenetic prenatal screening tests and related lab management rules affecting providers submitting claims for pregnant individuals.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPrenatal Screening (Nongenetic)

Policy CodePolicy CPCPLAB014

Change TypeAdded/Removed/Revised (multiple edits)

Effective DateNov 1, 2023

Next Review Date

Key ActionSubmit claims using HIPAA-approved code sets and be prepared to provide additional documentation upon request.

SourceLink

POLICY UPDATE CHANGES

Note references to other CPCP policies for thyroid screening (CPCPLAB019), fetal aneuploidy screening (CPCPLAB022), and Zika/vector-borne infection testing (CPCPLAB052) were added.

Screening for fetal aneuploidy was removed from the list and now referenced to another policy.

Prior language about testing pregnant women for thyroid dysfunction was removed and replaced by a reference to CPCPLAB019.

A clear statement that hCG testing is not reimbursable for normal uncomplicated pregnancies was added.

Terminology changed from 'women' to 'individuals' throughout the policy for inclusivity.

16+listed reimbursable routine prenatal screening items

50+procedure and CPT/HCPCS codes listed

13document reference list chunks

2023-07-17last committee approval date

Reimbursable Prenatal Screening Criteria

Reimbursable and non-reimbursable prenatal screening

Routine prenatal screening tests that may be reimbursable and conditional reimbursement rules.

ALL of the following

HIV infection screening
Chlamydia trachomatis infection screening
Neisseria gonorrhea infection screening
Hepatitis B screening
Syphilis screening

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPrenatal Screening (Nongenetic)

Policy CodePolicy CPCPLAB014

Change TypeAdded/Removed/Revised (multiple edits)

Effective DateNov 1, 2023

Next Review Date

Key ActionSubmit claims using HIPAA-approved code sets and be prepared to provide additional documentation upon request.

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.

Hepatitis C screening

Screening for bacteriuria

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 the first prenatal visit; repeat Rh(D) antibody testing at 24–28 weeks for all unsensitized Rh(D)-negative individuals unless the biological father is known to be Rh(D)-negative

Anemia screening (CBC or hemoglobin and hematocrit with mean corpuscular volume)

Group B Streptococcus screening (once), recommended at 36–37 weeks

Urinalysis and urine culture

Rubella antibody testing

Testing for varicella immunity

Tuberculosis screening for pregnant individuals deemed to be at high risk for TB

Third-trimester re-screening (conditional)

Age under 25 years
New or multiple sexual partners
History of sexually transmitted infections (examples: Bacterial Vaginosis, Chancroid, Chlamydia, Gonorrhea, Genital Herpes, Hepatitis B, Hepatitis C, HIV/AIDS, Human Papillomavirus, Lymphogranuloma Venereum, Syphilis, Trichomoniasis)
Past or current injection drug use

Rapid HIV in labor (conditional): Rapid HIV testing may be reimbursable for pregnant individuals who present in active labor with an undocumented HIV status.

Fetal fibronectin (FFN) — reimbursable when ALL criteria met

Singleton or twin gestation
Intact membranes
Cervical dilation < 3 cm
Symptoms suggestive of preterm labor between 24 and less than 35 weeks' gestation

Non-reimbursable tests

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.
FFN assays for situations not described above are not reimbursable.

Procedure and Code Guidance

FFN gestational window

Gestational windowFFN assays reimbursable only for symptomatic individuals between 24 and less than 35 weeks' gestation

Required clinical conditionsIntact membranes and cervical dilation <3 cm

Allowed gestationsSingleton or twin gestations only

Other restrictionsFFN assays not reimbursable in situations not meeting ALL listed criteria

Claim Submission and Conditional Reimbursement

Documentation Required

Claim submission and documentation

Submit claims using valid HIPAA‑approved code sets and industry-standard coding guidelines; code appropriately per UB, CPT, HCPCS, ICD-10, NDC, DRG, NCCI/CCI and other CMS guidance. Be prepared to provide additional documentation upon request; plan documents or provider contracts govern if conflicts arise.

Use valid code combinations from HIPAA‑approved code sets and industry standard coding guidelines (UB, AMA CPT, CPT Assistant, HCPCS, ICD-10 CM/PCS, NDC, DRG, CMS NCCI/CCI, etc.).
Claims are subject to code edit protocols and claim review; submit additional documentation upon request.
If a conflict exists between this policy and a plan document or provider contract, the plan document or provider contract governs.

Billing Rule

Reimbursable conditional tests — confirm criteria before billing

Confirm eligibility against the policy criteria before billing: rapid HIV testing may be reimbursable for individuals presenting in active labor with an undocumented HIV status; fetal fibronectin (FFN) assays are reimbursable only when ALL listed criteria are met. hCG testing is not reimbursable for individuals with a normal, uncomplicated pregnancy.

Rapid HIV testing: reimbursable when the pregnant individual presents in active labor with undocumented HIV status.
FFN assays: reimbursable only when all of the following are met — singleton or twin gestation; intact membranes; cervical dilation <3 cm; and symptoms suggestive of preterm labor between 24 and <35 weeks' gestation.
hCG hormone testing: not reimbursable for individuals with a normal pregnancy without complications.
Other FFN uses and serial salivary estriol monitoring are not reimbursable outside the specified indications.

Policy Definitions and High-Risk Criteria

Plan documents

Included documentsCertificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents

Governance priorityIf a conflict exists between this CPCP and a plan document, the plan document will govern

Provider contractsIf conflict exists between CPCP and a provider contract, the provider contract will govern

High-risk criteria for third-trimester re-screening

Age criterionIndividuals under 25 years of age are considered high-risk

Sexual behaviorNew or multiple sexual partners qualify as high-risk

STI historyHistory of sexually transmitted infections (e.g., Chlamydia, Gonorrhea, Syphilis, HIV, Hepatitis B/C, etc.) qualifies as high-risk

Injection drug usePast or current injection drug use qualifies as high-risk