CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLAB015

Hepatitis C Screening and Testing Reimbursement Policy

Defines BCBS Oklahoma laboratory reimbursement criteria for hepatitis C (HCV) screening, diagnostic, monitoring, and genotype testing for covered members, including recommended populations, monitoring intervals, and testing milestones related to therapy and acute infection.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyHepatitis C Screening and Testing Reimbursement Policy

Policy CodePolicy CPCPLAB015

Change TypeNew policy

Effective DateNov 1, 2022

Next Review Date

Key ActionProviders must submit accurate documentation of services performed and code claims using HIPAA-approved code sets; additional documentation may be requested.

SourceLink

POLICY UPDATE CHANGES

11/1/2022, 1 = New policy

1Policy Version

18-79One-time screening age range

5Viral load testing milestones

Coverage Summary

Scope: Defines BCBS Oklahoma laboratory reimbursement criteria for hepatitis C (HCV) screening, diagnostic, monitoring, and genotype testing for covered members, including recommended populations, monitoring intervals, and testing milestones related to therapy and acute infection. Overview: covered_with_criteria — BCBS Oklahoma policy on Hepatitis C screening and testing reimbursement, payer BCBS Oklahoma, effective Nov. 1, 2022.

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Medical-Necessity Criteria

One-time screening (age-based)

Screening at least once in a lifetime may be reimbursable when ALL of the following are met:

ALL of the following

Member is an adult between the ages of 18 years and 79 yearsAge 18-79 years
From policy: one-time lifetime screening reimbursable for adults 18-79
Screening is for Hepatitis C infection (one-time lifetime)one-time lifetime

Testing for adults with recognized conditions or exposures

Testing for Hepatitis C infection for all adults (≥18 years old) with recognized conditions or exposures may be reimbursable when ANY of the following exposures/conditions are present:

ANY of the following

Illicit intranasal or injectable drug use
Receipt of clotting factor concentrates produced before 1987
History of hemodialysis
Evidence of liver disease (based on clinical presentation, persistently abnormal alanine aminotransferase (ALT) levels, or abnormal liver function studies)
Presence of HIV infection
Receipt of an organ transplant before July 1992

Routine periodic testing for ongoing risk

Routine periodic HCV testing may be reimbursable while risk factors persist when ANY of the following ongoing risk factors are present:

ANY of the following

Individuals who currently inject drugs and share needles, syringes, or other drug preparation equipment
Individuals who are receiving ongoing hemodialysis

Genotype testing

One-time testing may be reimbursable when ALL of the following are met:

ALL of the following

Testing is for HCV genotype
Test is performed prior to initiation of treatment to guide selection of antiviral regimenprior to treatment

Monitoring in acute HCV infection

For patients with acute HCV infection, monitoring HCV RNA may be reimbursable when ALL of the following are met:

ALL of the following

Patient has acute HCV infection
HCV RNA testing performed to determine spontaneous clearance versus persistence
Testing performed every 4 to 8 weeks for 6 to 12 monthsevery 4–8 weeks for 6–12 months
Monitoring interval from policy: every 4 to 8 weeks for 6 to 12 months

HCV viral load testing (quantitative NAT) related to therapy

Testing for HCV viral load using a quantitative nucleic acid test may be reimbursable when ALL of the following clinical milestones are met:

ALL of the following

Prior to initiation of HCV therapyprior to initiation of therapy
After 4 weeks of therapy4 weeks on therapy
At the end of treatmentend of treatment
12 weeks after completion of treatment12 weeks post-treatment

Provider Actions

Documentation Required

Submit accurate documentation and valid codes

Providers are responsible for submission of accurate documentation of services performed. Providers are expected to submit claims for services rendered using valid code combinations from HIPAA‑approved code sets (CPT, HCPCS, ICD-10, NDC) and industry standard coding guidelines; additional documentation may be requested.

Billing Rule

Claims subject to code edit protocols and review

Claims for HCV screening and testing are subject to code edit protocols, claim review, and applicable benefit/contract terms; providers should ensure appropriate coding to avoid denials.

Background & Evidence

BCBS Oklahoma implemented certain lab management reimbursement criteria for hepatitis C testing. The policy notes that not all requirements apply to each product and that providers are urged to review Plan documents (for example: Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents) because plan documents or provider contracts will govern in the event of a conflict. Providers are responsible for submitting accurate documentation and coding claims using HIPAA-approved code sets; claims are subject to code edit protocols and review and additional documentation may be requested.

Primary guideline references: AASLD-IDSA, CDC, USPSTF, WHO and additional professional society and literature sources cited in the policy (2015–2020).

OpenPayer

Hepatitis C Screening and Testing Reimbursement Policy

Coverage Summary

Medical-Necessity Criteria

Coding

Provider Actions

Background & Evidence

Revision History