Blue Cross Blue Shield OK Hepatitis Testing Coverage Update

Coverage Criteria for Hepatitis Testing

inv-01: Hepatitis B screening and follow-up

Covered when ANY of the following conditions are met:

HBV lifetime and annual screening: 1. For all individuals 18 years of age and older, triple panel testing (HBsAg, anti-HBs, anti-HBc) once per lifetime may be reimbursable. 2. For asymptomatic, non-pregnant individuals, annual HBV infection screening may be reimbursable for listed high-risk situations 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 ≥8%; history of incarceration; HIV infection; history of sexually transmitted infections or multiple sex partners; men who have sex with men; household/needle-sharing/sex partners of HBV-infected persons; injection-drug users; active or history of HCV; elevated liver enzymes; long-term hemodialysis; diabetes; healthcare/public safety workers exposed to blood/body fluids.

See Note 1 for geographic prevalence reference

inv-02: HBV follow-up and pre-immunosuppression testing

Covered when ALL of the following are met:

HBV follow-up testing: For individuals who test positive for anti-HBc, follow-up IgM anti-HBc testing to distinguish acute versus chronic infection may be reimbursable. For confirmation of seroconversion after hepatitis B vaccination, anti-HBs testing may be reimbursable. For individuals who test positive for HBV by initial antibody screening and who will undergo immunosuppressive drug therapy, HBV DNA testing may be reimbursable.

inv-03: Hepatitis C screening, diagnosis, and monitoring

Covered when ANY of the following are met:

HCV lifetime antibody screening: For all individuals 18 years of age and older, antibody testing for HCV infection once per lifetime may be reimbursable.

HCV one-time post-exposure or risk-based testing: One-time, post-exposure antibody testing for HCV may be reimbursable for recognized conditions or exposures including illicit intranasal/injectable drug use; receipt of clotting factor concentrates 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 recipient of blood from a donor later positive for HCV; history of incarceration; unregulated tattoos; healthcare/public safety worker exposures; children born to HCV-positive individuals; current sexual partners of HCV-infected persons.

HCV routine periodic testing for ongoing risk: Routine periodic antibody testing may be reimbursable while ongoing risk factors persist for people who inject drugs and share equipment, individuals receiving ongoing hemodialysis, and individuals engaging in high-risk sexual behavior.

inv-04: Hepatitis A and D testing

Covered when ALL of the following are met:

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

HDV testing: For individuals who have tested positive for HBV, testing for HDV antibody (anti-HDV) or qualitative HDV RNA may be reimbursable. Quantitative HDV RNA testing is not reimbursable.

inv-05: HCV nucleic acid testing reimbursable situations

Examples of reimbursable testing as revised in policy update history

HCV nucleic acid testing reimbursable situations: Nucleic acid testing for HCV may be reimbursable in any of the following situations: a) As a follow-up for individuals who test positive for HCV by initial antibody screening (to differentiate active versus resolved infection); b) One-time screening for perinatally exposed infants who are 2–6 months of age; c) Other clinical situations listed in policy (e.g., indications related to treatment monitoring and pre-treatment assessment).

Qualitative NAT specified for some situations

inv-06: HAV testing

Hepatitis A testing

HAV testing for symptomatic individuals: 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 testing for HAV RNA may be reimbursable.

Quantitative HAV viral load is not reimbursable.

inv-07: HDV testing

Hepatitis D testing

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

Quantitative HDV viral load is not reimbursable.

inv-08: HBV triple panel

Hepatitis B screening

HBV triple panel for adults: For all individuals 18 years of age and older, triple panel testing (HBsAg, anti-HBs, total anti-HBc) for Hepatitis B infection once per lifetime may be reimbursable.once per lifetime

Quantitative nucleic acid testing for hepatitis A virus (HAV) viral load is explicitly listed as not reimbursable. The policy permits testing for IgM anti-HAV or qualitative HAV RNA for individuals with signs and symptoms of acute viral hepatitis who have tested negative for HBV and HCV, but it clearly states that quantitative HAV RNA (viral load) is not reimbursable.

Quantitative nucleic acid testing for hepatitis D virus (HDV) viral load is explicitly listed as not reimbursable. The policy allows anti-HDV or qualitative HDV RNA testing for individuals who have tested positive for HBV, but states that quantitative HDV RNA (viral load) is not reimbursable.

The policy explicitly classifies quantitative nucleic acid testing for HAV and HDV viral loads as non-covered / not reimbursable. This language appears in the Policy Update History and under the Hepatitis D section, confirming that while certain qualitative assays and serologies may be reimbursed, quantitative NAT for HAV and HDV will not be paid.

Specific Covered Indications

Testing Frequency and Limits

inv-32: HBV triple panel (HBsAg, anti-HBs, anti-HBc) and HCV antibody testing for individuals ≥18 years — once

TestHBsAg, anti-HBs, anti-HBc triple panel and HCV antibody testing

PopulationIndividuals 18 years of age and older

FrequencyOnce (lifetime)

Policy referenceCPCPLAB015 — Hepatitis B and C reimbursement items (see Reimbursement Information #1 and #6)

inv-33: HBV screening for asymptomatic, non-pregnant individuals with listed high-risk situations — once per year

TestHBsAg and anti-HBs (or triple panel HBsAg/anti-HBs/anti-HBc)

Procedure and Test Codes

Listed procedure codesmixed

86692
86704
86705
86706
86708
86709
86803
86804
87340
87341

1–10 of 21

1/3

Added/mentioned test codesmixed

86692	Added code (document lists added codes)
86708	Added code (document lists added codes)
86709	Added code (document lists added codes)
87380	Added code (document lists added codes)
87523	Added code (document lists added codes)

inv-14: Age threshold for routine lifetime screening — 18 years and older

Age threshold18 years and older

Applies toRoutine antibody/triple panel screening for HBV and HCV as specified in policy

Frequency implicationWhere specified, testing offered once (lifetime) for adults ≥18 unless other risk indications warrant more frequent testing

inv-15: Perinatally exposed infant one-time HCV screen age — 2-6 months

TestQualitative HCV nucleic acid test (NAT)

PopulationPerinatally exposed infants

Provider Responsibilities and Billing Notes

Prior Authorization

Product-specific plan review

BCBSOK has implemented certain lab management reimbursement criteria that may not apply to every product. Providers must review member-specific plan documents (Certificates of Coverage, benefit booklets, Summary Plan Descriptions, and other coverage documents) to confirm eligibility and any product-specific limitations before ordering or billing tests.

Review plan documents for product-specific coverage and limits
Plan documents and provider contracts govern when in conflict with this policy

Prior Authorization

Added test codes — verify prior authorization

Some tests added to this policy may be subject to prior authorization or payer-specific rules. Verify prior authorization and billing requirements for newly listed codes with the payer before performing services.

Confirm PA requirements for added codes: 86692, 86708, 86709, 87380, 87523
Check payer/provider portals or contact BCBSOK Provider Services for code-specific PA rules

Ordering and Prior Authorization Considerations

Note

Confirm product-specific ordering eligibility

Not all ordering requirements apply to every BCBSOK product; providers must review the member’s plan documents to determine product-specific eligibility before ordering hepatitis testing.

Documentation Required

Order tests only for policy-specified clinical indications

Order hepatitis testing only when policy-specified clinical indications are met; the policy lists indications such as symptomatic acute viral hepatitis, positive HBV/HCV status, and perinatal exposure for reimbursable tests.

Examples: IgM anti-HAV or qualitative HAV RNA for symptomatic individuals who tested negative for HBV/HCV; anti-HDV or qualitative HDV RNA for HBV-positive individuals; qualitative HCV NAT as follow-up to positive antibody or one-time screen for perinatally exposed infants aged 2–6 months.

Services Not Reimbursable

Under the policy's Not Covered provisions, quantitative nucleic acid testing to measure HAV viral load is specifically listed as not reimbursable. The policy retains coverage for IgM anti-HAV or qualitative HAV RNA in symptomatic, HBV/HCV-negative individuals, but disallows viral load testing for HAV.

The policy's Not Covered statements also include quantitative nucleic acid testing for HDV viral load as not reimbursable. Qualitative HDV RNA or anti-HDV testing for HBV-positive individuals may be covered, but quantitative HDV RNA testing is excluded from reimbursement.

Background and Scope

Hepatitis viruses (A, B, C, D) are evaluated using a combination of serologic assays and nucleic acid tests to identify acute versus chronic infection, guide treatment decisions, and confirm immunity. The policy documents that: for Hepatitis B, a triple panel (HBsAg, anti-HBs, total anti-HBc) is used for screening and may be reimbursable once per lifetime for adults ≥18; for Hepatitis C, both antibody testing and nucleic acid testing (qualitative for diagnosis and qualitative/quantitative as specified for monitoring and treatment) are addressed; and for Hepatitis A and D, serology (IgM anti-HAV, anti-HDV) or qualitative NAT may be reimbursable in the indicated clinical contexts while the policy excludes quantitative HAV and HDV viral load testing.

Key Definitions

inv-25: HBsAg / anti-HBs / anti-HBc triple panel — Combined serologic testing used to determine infection, immunity, or prior exposure.

ComponentsHepatitis B surface antigen (HBsAg), hepatitis B surface antibody (anti‑HBs), total hepatitis B core antibody (anti‑HBc)

PurposeCombined serologic testing used to determine current infection (HBsAg), immunity (anti‑HBs), or prior/ongoing exposure (anti‑HBc)

UsageReferenced as the recommended triple panel for adult screening and for risk‑based annual screening situations

inv-26: HCV RNA (qualitative and quantitative) — Nucleic acid testing to determine active HCV infection (qualitative) or measure viral load (quantitative).

TestHCV RNA nucleic acid testing (qualitative and quantitative)

Qualitative use

Policy Update History

2025-01-15effective_dateLatest

Document effective date after literature review; Reimbursement Information #9 edited to specify 'qualitative' nucleic acid testing for HCV and to clarify situations where testing may be reimbursable.

2024-10-30revision

Document updated with literature review noting upcoming effective date 01/15/2025 and edits to Reimbursement Information #9 and infant screening age per CDC guidance.

2024-03-15revision