ModifiedBlue Cross Blue Shield - OklahomaPolicy CPCPLABO15

Hepatitis Testing

Reimbursement and laboratory testing criteria for hepatitis A, B, C, and D screening, diagnostic, and follow-up tests for Blue Cross Blue Shield of Oklahoma members and providers submitting claims.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyHepatitis Testing (clinical coverage criteria for HBV, HCV, HAV, HDV)

Policy CodePolicy CPCPLABO15

Change TypeMaterial revisions and additions (qualitative testing clarifiedHAV/HDV guidance and codes added)

Effective DateJan 15, 2025

Next Review DateN/A

Key ActionWhen billing qualitative nucleic acid testing for HCV, HAV, or HDV, include supporting clinical documentation that matches the reimbursable indications (e.g., symptomatic HAV after negative HBV/HCV; HBV-positive for HDV; follow-up of positive HCV antibody or perinatal infant screening at 2-6 months).

SourceLink

POLICY UPDATE CHANGES

Reworded nucleic acid testing guidance for HCV to specify 'qualitative' testing in certain circumstances and clarified infant screening age from '2-17' to '2-6' months.

Hepatitis A and hepatitis D testing guidance were added, including reimbursable qualitative testing and non-reimbursable quantitative viral load testing.

Added procedure codes 86692, 86708, 86709, 87380, 87523 to the code list.

Qualitative nucleic acid testing for HCV may be reimbursable in specified situations and age ranges for perinatally exposed infants were changed from 2-17 months to 2-6 months.

Testing statements for hepatitis A and hepatitis D were added, including that IgM anti-hepatitis A or qualitative HAV RNA may be reimbursable for symptomatic individuals who test negative for HBV and HCV, and that anti-HDV or qualitative HDV RNA may be reimbursable for individuals positive for HBV.

Several CPT/HCPCS codes were added to the policy's code set: 86692, 86708, 86709, 87380, 87523.

Hepatitis B section was added/expanded to state that HBsAg, anti-HBs, and total anti-HBc once per lifetime may be reimbursable and related criteria were reorganized.

Multiple reimbursement statement additions and clarifications across Hepatitis B and C including added or edited numbered statements (e.g., new #1,2,3,4,8 noted in history).

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.

15+reimbursement items

5codes added

1HBV lifetime panel

1HCV lifetime antibody

qualitative onlynucleic acid stance

Coverage and Reimbursement Criteria

Hepatitis B - Covered criteria

Covered when any of the following HBV criteria are met

HBV screening and follow-up: - Adults >=18: one-time HBV triple panel (HBsAg; anti-HBs; total anti-HBc) may be reimbursable; - For asymptomatic, non-pregnant individuals, annual HBV triple panel testing may be reimbursable when one or more high-risk situations are present, including: infants born to HBsAg-positive individuals; individuals born in or recently traveled to regions with HBV prevalence >=2%; U.S.-born individuals not vaccinated as infants whose parents were born in regions with HBV prevalence >=2%; history of incarceration; HIV infection; history of sexually transmitted infections or multiple sex partners; men who have sex with men; household, needle-sharing, or sexual contacts of HBV-infected persons; injection-drug users; individuals with elevated liver enzymes; individuals with active or past HCV infection; long-term hemodialysis; healthcare or public safety workers exposed to blood/body fluids; individuals with diabetes.

Follow-up IgM anti-HBc may be reimbursable for anti-HBc positive individuals to distinguish acute vs chronic infection; HBV DNA testing may be reimbursable for individuals who test positive by initial antibody screening prior to immunosuppressive therapy.

Hepatitis C - Covered criteria

Covered when any of the following HCV criteria are met

HCV screening and follow-up: - Adults >=18: one-time HCV antibody testing may be reimbursable; - One-time post-exposure antibody testing may be reimbursable for recognized exposures/conditions (e.g., illicit intranasal or injectable drug use; receipt of clotting factor concentrates produced before 1987; history of hemodialysis; evidence of liver disease or persistently abnormal ALT; HIV infection; organ transplant before July 1992; blood transfusion or blood component before July 1992; notified that blood received was from a donor later positive for HCV; unregulated tattoo; history of incarceration; healthcare/public safety workers after needle sticks/sharps/mucosal exposures to HCV-positive blood; current sexual partners of HCV-infected persons; children born to HCV-positive individuals); - Routine periodic antibody testing may be reimbursable while ongoing risk factors persist (ongoing hemodialysis; current injection drug use with sharing; high-risk sexual behavior); - Qualitative nucleic acid testing may be reimbursable as follow-up for individuals who test positive by initial antibody screening to differentiate active vs resolved infection; and as one-time screening for perinatally exposed infants aged 2-6 months (policy revised to emphasize qualitative testing and change infant window to 2-6 months); - HCV genotype testing may be reimbursable prior to initiation of direct-acting antiviral therapy to guide regimen selection; - Nucleic acid testing during and after DAA therapy may be reimbursable at specified time points (prior to initiation, after 4 weeks, end of treatment, and at 12, 24, and 48 weeks post-treatment).

Policy revised to specify qualitative nucleic acid testing and to narrow perinatal infant screening age to 2-6 months.

Hepatitis A and D - Covered and not covered

Covered when the following are met

Hepatitis A: - For individuals with signs and symptoms of acute viral hepatitis who have tested negative for HBV and HCV, IgM anti-HAV testing or qualitative HAV RNA testing may be reimbursable; - Quantitative HAV viral load testing is not reimbursable.

Hepatitis D: - For individuals who have tested positive for HBV, anti-HDV antibody testing or qualitative HDV RNA testing may be reimbursable; - Quantitative HDV viral load testing is not reimbursable.

Reimbursable testing scenarios

Selected reimbursable testing statements added or revised for hepatitis A, B, C, and D include:

Hepatitis C nucleic acid testing: Nucleic acid testing for HCV may be reimbursable as a follow-up for individuals who test positive for HCV antibody to differentiate active vs resolved infection; and as one-time screening for perinatally exposed infants aged 2-6 months (previously 2-17 months).

Qualitative testing language emphasized in update.

Hepatitis A symptomatic testing: For individuals with signs and symptoms of acute viral hepatitis who have tested negative for HBV and HCV, testing for IgM anti-hepatitis A (HAV) or qualitative HAV RNA may be reimbursable.

Quantitative HAV viral load testing is not reimbursable.

Hepatitis D testing: For individuals who have tested positive for HBV, testing for hepatitis D virus (anti-HDV) or qualitative HDV RNA may be reimbursable.

Quantitative HDV viral load testing is not reimbursable.

Quantitative nucleic acid testing for hepatitis A virus (HAV) viral load is not reimbursable. For symptomatic individuals being evaluated for acute viral hepatitis who have tested negative for HBV and HCV, IgM anti-HAV or qualitative HAV RNA testing may be reimbursable, but quantitative HAV RNA testing is explicitly excluded from reimbursement.

Quantitative nucleic acid testing for HAV and for HDV viral load is not reimbursable. The policy specifies that while qualitative HAV RNA or anti-HAV IgM testing may be reimbursable in symptomatic individuals (after negative HBV/HCV testing) and qualitative HDV RNA or anti-HDV testing may be reimbursable for HBV-positive individuals, quantitative viral load assays for HAV and HDV are excluded from coverage.

For operational clarity: when billing for hepatitis A or D testing, submit claims for IgM anti-HAV, qualitative HAV RNA, anti-HDV, or qualitative HDV RNA when the clinical indications in the policy are met. Do not expect reimbursement for quantitative HAV or HDV viral load testing, as those assays are not covered.

Operational interpretation: Quantitative nucleic acid testing for HDV viral load is not reimbursable. For members who test positive for HBV, coverage may apply to anti-HDV or qualitative HDV RNA testing only; quantitative HDV RNA assays should not be billed for reimbursement under this policy.

Covered Indications by Hepatitis Type

Screening, diagnostic follow-up, and monitoring

Screening, diagnostic follow-up, and monitoring for HBV, HCV, HAV, and HDV are covered for adults and specified high-risk groups and exposures as enumerated below.

Adult one-time screening: - HBV: Adults >=18 — one-time HBV triple panel (HBsAg; anti-HBs; total anti-HBc) may be reimbursable (once per lifetime). - HCV: Adults >=18 — one-time HCV antibody testing may be reimbursable (once per lifetime).once per lifetime

High-risk and exposure-based screening/follow-up: - HBV: Annual or targeted triple panel testing for asymptomatic, non-pregnant individuals when high-risk criteria are present (see HBV criteria list) and follow-up IgM anti-HBc for anti-HBc positive individuals may be reimbursable. - HCV: One-time post-exposure antibody testing and routine periodic antibody testing while risk persists are reimbursable for the enumerated exposures and ongoing risk factors; qualitative HCV nucleic acid testing reimbursable to confirm active infection after positive antibody. - HAV: IgM anti-HAV or qualitative HAV RNA may be reimbursable for symptomatic individuals who tested negative for HBV and HCV. - HDV: Anti-HDV or qualitative HDV RNA may be reimbursable for individuals positive for HBV.

Documentation should support use of qualitative nucleic acid testing when billed under these indications.

Procedure Codes and Frequency

Procedure codes addedCPT

86692	Listed added code (document did not supply textual description)
86708	Listed added code (document did not supply textual description)
86709	Listed added code (document did not supply textual description)
87380	Listed added code (document did not supply textual description)
87523	Listed added code (document did not supply textual description)

Added codesCPT

86692	added code (document lists newly added code)
86708	added code (document lists newly added code)
86709	added code (document lists newly added code)
87380	added code (document lists newly added code)
87523	added code (document lists newly added code)

Perinatal infant HCV screening age — Updated window to 2-6 months

Perinatal infant HCV screening windowOne-time screening for perinatally exposed infants aged 2-6 months (policy revised from 2-17 to 2-6 months)

Test type specifiedQualitative nucleic acid testing for HCV is the specified method for this one-time infant screen

PurposeDetect active HCV infection in infants born to HCV-positive individuals

Testing Frequency and Repeat Testing Limits

HBV triple panel and HCV antibody — Frequency limits

HBV triple panel (adults >=18)One-time testing (HBsAg, anti-HBs, total anti-HBc) once per lifetime

HCV antibody (adults >=18)One-time HCV antibody testing once per lifetime

Age thresholdApplies to individuals 18 years of age and older

Routine periodic HCV antibody testing for ongoing risk factors

Routine periodic HCV antibody testingPeriodic testing while ongoing risk factors persist (e.g., hemodialysis, active injection drug use with sharing, high-risk sexual behavior)

Examples of ongoing riskReceiving ongoing hemodialysis; current injection drug use with sharing; engaging in high-risk sexual behavior

Provider Responsibilities and Billing Guidance

Documentation Required

Claims Documentation and Code Submission

Providers are responsible for submission of accurate documentation of services performed and must submit claims using appropriate, valid codes from HIPAA-approved code sets. Claims should be coded according to industry-standard coding guidelines (eg, AMA CPT, HCPCS, ICD-10-CM/PCS, NDCs, DRG rules) and are subject to code edit protocols, provider contract language, plan benefits, medical policies, and coding software logic. Providers may be asked to submit additional documentation upon request. Providers should verify plan-specific requirements and benefit coverage prior to billing.

Submit claims using appropriate, valid codes from HIPAA-approved code sets.
Claims are subject to code edit protocols and plan/contract rules; denials may occur if documentation or coding is insufficient.

Billing Rule

Code Inclusion and Plan-Specific Requirements

Ordering and Eligibility Notes

Note

Ordering requirements — verify product-specific coverage and eligibility

Providers must follow plan documents for eligibility and coverage determinations; the policy notes that not all requirements apply to every product and urges verification with plan documents before ordering or billing.

Verify member eligibility and any product-specific requirements in the applicable Certificate of Benefits or plan documents.
When in doubt, confirm coverage and prior authorization requirements with the plan.

Note

Ordering provider limitations — none specified in policy text

The policy contains no explicit limitations specifying which provider types may place orders for the tests in these cited sections; follow any ordering/provider restrictions that appear in the member's plan documents or provider contract.

If a plan document or contract includes ordering provider limitations, follow those requirements; the policy itself does not specify ordering provider restrictions in the cited text.

Services Not Reimbursable

Not covered: Quantitative nucleic acid testing for HAV and HDV viral load is explicitly not reimbursable. This exclusion applies regardless of clinical scenario; providers should use the reimbursable qualitative tests or serology described in the policy when clinically indicated.

Not covered: The policy history and reimbursement statements confirm that quantitative nucleic acid testing for HAV and HDV viral load is not reimbursable, and claims for those quantitative viral load tests may be denied.

Key Definitions and Test Descriptions

HBV triple panel — Definition

DefinitionHBV triple panel includes hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (anti-HBs), and total antibody to hepatitis B core antigen (anti-HBc)

Intended useBaseline screening, identification of immunity, and detection of current or past infection

Frequency guidanceOnce per lifetime for adults >=18 when indicated

Qualitative nucleic acid testing (HCV/HAV/HDV) — Definition

DefinitionQualitative nucleic acid amplification testing: testing reported as qualitative detection of viral RNA used in specific follow-up or screening scenarios (e.g., HCV follow-up after positive antibody; qualitative HAV/HDV RNA in specified situations)

Distinguishing roleFor HCV: differentiates active vs resolved infection after a positive antibody test

Policy Scope and Background

This policy provides clinical testing and reimbursement criteria for hepatitis B (HBV), hepatitis C (HCV), hepatitis A (HAV), and hepatitis D (HDV). It includes one-time screening guidance (e.g., HBV triple panel and HCV antibody for adults ≥18), recommended follow-up testing (including qualitative nucleic acid testing for HCV in specified situations and for perinatally exposed infants aged 2-6 months), monitoring schedules for HCV treatment, and specific statements that quantitative nucleic acid testing for HAV and HDV viral load is not reimbursable. The policy cites added procedure codes and clarifies documentation and coding expectations for laboratory claims.

Policy Update History

2025-01-15material_revisionLatest

Document updated with literature review: item #9 edited to specify 'qualitative' HCV nucleic acid testing and the perinatally exposed infant screening age narrowed from 2-17 months to 2-6 months.

2024-10-30effective_date

Policy update history records literature review and lists changes that became effective 2025-01-15, including edits to HCV nucleic acid testing language and additions for hepatitis A and D testing statements.

2023-11-01

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyHepatitis Testing (clinical coverage criteria for HBV, HCV, HAV, HDV)

Policy CodePolicy CPCPLABO15

Change TypeMaterial revisions and additions (qualitative testing clarifiedHAV/HDV guidance and codes added)

Effective DateJan 15, 2025

Next Review DateN/A

SourceLink

On This Page

Hepatitis B baseline testing: Hepatitis B testing (HBsAg, anti-HBs, total anti-HBc) once per lifetime may be reimbursable; additional risk groups and combined criteria were added or clarified.once per lifetime

Risk groups include incarceration history, HIV infection, STI/multiple sex partners, active or history of HCV infection, elevated liver enzymes, long-term hemodialysis, diabetes.

Monitoring and treatment-related testing: - HCV: Genotype testing prior to direct-acting antiviral initiation and nucleic acid testing at specified time points during and after DAA therapy (prior to initiation, after 4 weeks, end of treatment, and at 12, 24, and 48 weeks post-treatment) may be reimbursable. - HBV: HBV DNA testing may be reimbursable prior to immunosuppressive therapy for those positive by initial antibody screening.

HCV follow-up and perinatal infant screening

Qualitative nucleic acid testing may be reimbursable in these HCV follow-up and perinatal screening situations

Follow-up of positive HCV antibody: Qualitative HCV nucleic acid testing may be reimbursable as follow-up to a positive HCV antibody result to differentiate active infection from resolved infection.

Perinatal infant screening: One-time qualitative HCV nucleic acid testing may be reimbursable for perinatally exposed infants aged 2-6 months.one time; 2-6 months

Policy update narrowed infant screening window from 2-17 to 2-6 months.

HAV symptomatic testing after negative HBV and HCV

Symptomatic HAV testing after negative HBV and HCV

HAV symptomatic testing: For individuals with signs and symptoms of acute viral hepatitis who have tested negative for HBV and HCV, IgM anti-HAV testing or qualitative HAV RNA testing may be reimbursable.

Quantitative HAV RNA testing is not reimbursable and claims may be denied.

HDV testing for individuals positive for HBV

HDV testing: For individuals who have tested positive for HBV, anti-HDV antibody testing or qualitative HDV RNA testing may be reimbursable.

Quantitative HDV RNA (viral load) testing is not reimbursable and is specifically excluded.

HBV baseline testing (HBsAg, anti-HBs, total anti-HBc) once per lifetime

HBV baseline testing once per lifetime for indicated individuals and risk groups

HBV baseline triple panel: Hepatitis B baseline testing including HBsAg, anti-HBs, and total anti-HBc may be reimbursable once per lifetime for adults (>=18) and for indicated risk groups (see HBV criteria list).once per lifetime

Risk groups include those listed under HBV criteria (e.g., incarceration history, HIV infection, STI/multiple sex partners, active or history of HCV infection, elevated liver enzymes, long-term hemodialysis, diabetes).

Frequency noteNo fixed interval specified — repeat while risk persists

HBsAg, anti-HBs, total anti-HBc — Frequency limits

HBV baseline panelHBsAg, anti-HBs, and total anti-HBc — once per lifetime may be reimbursable for indicated individuals and risk groups

Applies toAdults 18 years of age and older and other indicated risk groups described in policy

PurposeBaseline screening and identification of immunity or prior infection

HCV qualitative nucleic acid testing for perinatally exposed infants

HCV qualitative nucleic acid testing for infantsOne-time qualitative nucleic acid test for perinatally exposed infants aged 2-6 months

MethodQualitative nucleic acid amplification testing (reported as detection of viral RNA)

PurposeUsed to identify active HCV infection in perinatally exposed infants

BCBSOK has implemented certain laboratory management reimbursement criteria. Not all requirements apply to each product; inclusion of a procedure code in the policy or reimbursement information does not guarantee coverage. Providers should review plan documents and verify eligibility/coverage for the member prior to ordering or billing tests.

Inclusion of a code in the policy is not a guarantee of coverage — verify member benefit documents.
Reimbursement criteria may vary by product.

Note

Added Test Codes — Verify Plan Requirements

Added test codes to the reimbursement information. Providers should note these additions and bill using the appropriate codes when supported by documentation and member benefits. No prior authorization statement was found with the code additions; however, providers must confirm whether prior authorization or other plan-specific requirements apply before performing or billing the test.

Added codes: 86692, 86708, 86709, 87380, 87523.
No explicit prior authorization statement was found with the code additions; verify plan PA requirements.

Documentation Required

Supporting Clinical Documentation and Non-Reimbursable Tests

Qualitative nucleic acid testing for HCV, HAV, or HDV may be reimbursable in specified clinical situations. Documentation should support the medical necessity and the specific reimbursable indication under which the test is billed. Quantitative nucleic acid testing for HAV and for HDV viral load is not reimbursable and claims for those tests may be denied.

Qualitative nucleic acid testing for HCV may be reimbursable in specified situations (see Reimbursement Information).
Qualitative testing for HAV RNA and HDV RNA may be reimbursable for certain clinical indications.
Quantitative nucleic acid testing for HAV and HDV viral load is not reimbursable — claims may be denied.

Denial Risk

Claim Submission Risk and Denial Conditions

Claims are subject to denial risk if submitted without proper documentation, if billed with non-reimbursable quantitative viral load tests (eg, HAV or HDV), or if coding conflicts with plan/contract rules or coding edits. Providers are urged to verify member coverage, conform to plan-specific billing requirements, and submit supporting clinical documentation when requested.

Claims for quantitative HAV and HDV viral load testing may be denied (non-reimbursable).
Providers should verify member coverage and any prior authorization requirements before billing.
Maintain supporting clinical documentation to justify qualitative nucleic acid testing when billed under reimbursable indications.

LimitationsQuantitative viral load testing is explicitly not reimbursable for HAV and HDV

Perinatally exposed infant screening window — History updated

Updated infant screening windowPerinatally exposed infant screening window was previously described as 2-17 months and is updated to 2-6 months for one-time qualitative HCV nucleic acid testing

Policy history noteChange documented in policy update history (10/30/2024; effective 01/15/2025) with language edited to specify 'qualitative' testing and narrowed age range

Operational impactOne-time qualitative HCV NAT reimbursable only within the 2-6 month window for perinatally exposed infants per revised policy

literature_review_update

Document updated with literature review to add multiple Hepatitis C reimbursement statements (#1,2,3,4,8), specify antibody screening for initial HCV screening, and revise timing language (e.g., added 'forty-eight weeks' in monitoring schedule).