ModifiedBlue Cross Blue Shield - OklahomaPolicy CPCPLABO15

Hepatitis Testing

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Lab management reimbursement criteria for hepatitis testing (B, C, A, D) outlining when specific serologic and nucleic acid tests may be reimbursable for BCBS Oklahoma members; affects ordering providers and laboratory billing for covered products.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyHepatitis Testing

Policy CodePolicy CPCPLABO15

Change TypeMaterial updates to testing indications, frequencies, and code list

Effective DateNov 7, 2025

Next Review Date

Key ActionCheck member plan documents for product-specific coverage and reference this policy when billing the newly appended laboratory codes.

SourceLink

POLICY UPDATE CHANGES

Nucleic acid testing for HCV was revised to be reimbursable in multiple specified situations including follow-up after positive antibody screening and one-time screening for perinatally exposed infants.

Antibody testing for HCV once every three months may be reimbursable for individuals with ongoing risk factors while risk factors persist.

New language added clarifying testing for hepatitis A and hepatitis D, including that quantitative viral load testing for HAV and HDV is not reimbursable while qualitative testing or IgM for HAV and anti-HDV or qualitative HDV RNA may be reimbursable in specified situations.

Several laboratory CPT/HCPCS codes were added to the policy's reimbursable code list (e.g., 86692, 86708, 86709, 87380, 87523, 87516, 87799, G0567).

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

ModifiedBlue Cross Blue Shield - OklahomaPolicy CPCPLABO15

Hepatitis Testing

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Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyHepatitis Testing

Policy CodePolicy CPCPLABO15

Change TypeMaterial updates to testing indications, frequencies, and code list

Effective DateNov 7, 2025

Next Review Date

Key ActionCheck member plan documents for product-specific coverage and reference this policy when billing the newly appended laboratory codes.

SourceLink

POLICY UPDATE CHANGES

Antibody testing for HCV once every three months may be reimbursable for individuals with ongoing risk factors while risk factors persist.

Several laboratory CPT/HCPCS codes were added to the policy's reimbursable code list (e.g., 86692, 86708, 86709, 87380, 87523, 87516, 87799, G0567).

multiplepolicy document updates since 2022

2-6 moHCV perinatal screening window

q3 monthsHCV antibody frequency (ongoing risk)

not reimbursableQuantitative HAV/HDV NA testing

≥8new laboratory codes appended

Coverage Criteria for Hepatitis Testing

inv-01: HBV Screening Criteria

Covered when any of the following HBV screening criteria are met

HBV screening (asymptomatic, non-pregnant annual)

High-risk situations: Includes infants born to HBsAg-positive individuals; individuals born in or who have recently traveled to geographic regions with an HBV prevalence >= 2%; U.S.-born individuals not vaccinated as infants whose parents were born in regions with HBV prevalence >= 2%; people infected with HIV; history of incarceration; history of sexually transmitted infections or multiple sex partners; men who have sex with men; injection-drug users; household/needle-sharing contacts and sex partners of HBV-infected individuals; individuals with active or history of HCV infection; long-term hemodialysis; elevated liver enzymes; diabetes; individuals receiving immunosuppressant therapy; healthcare or public safety workers exposed to blood or body fluids.

inv-02: HBV Follow-up and Confirmation

Follow-up and confirmatory HBV testing

HBV follow-up: If anti-HBc positive, IgM anti-HBc testing to distinguish acute vs chronic infection may be reimbursable; anti-HBs testing may be reimbursable to confirm seroconversion after vaccination; HBV DNA testing may be reimbursable for individuals who screen antibody-positive and will undergo immunosuppressive therapy.

inv-03: HCV Screening and Recurring Testing

HCV screening and recurring testing

HCV one-time screening: Antibody testing for HCV reimbursable once per lifetime for all individuals >=18 years of age.

HCV post-exposure/one-time testing indications: One-time, post-exposure antibody testing reimbursable for recognized conditions or exposures including illicit intranasal or injectable drug use; receipt of clotting factor concentrates produced before 1987; history of hemodialysis; evidence of liver disease or persistently elevated ALT; HIV infection; organ transplant before July 1992; receipt of blood transfusion or blood from a donor before July 1992; history of incarceration; healthcare/public safety workers after occupational exposures; unregulated tattooing; children born to HCV-positive individuals; current sexual partners of HCV-infected persons.

HCV recurring testing: Antibody testing every 3 months may be reimbursable for individuals with ongoing risk factors while risks persist (e.g., ongoing hemodialysis, current injection drug use with shared equipment, high-risk sexual behavior; includes immunocompromised individuals and those receiving immunosuppressant therapy as noted in updates).every 3 months

inv-04: HCV Diagnostic and Treatment Monitoring

HCV diagnostic and monitoring testing

HCV qualitative NAT: Qualitative nucleic acid testing (NAT) reimbursable as follow-up to a positive HCV antibody (to differentiate active vs resolved infection), for immunocompromised individuals, and for one-time screening of perinatally exposed infants aged 2-6 months.

Per policy update the infant age window revised to 2-6 months.

HCV genotype before DAA: One-time HCV genotype testing reimbursable prior to initiation of direct-acting antiviral (DAA) therapy to guide regimen selection.

HCV viral load monitoring: Quantitative HCV viral load testing reimbursable prior to initiation of DAA therapy, after 4 weeks of therapy, at the end of treatment, and at 12, 24, and 48 weeks after completion of treatment.

inv-05: HAV and HDV Testing

HAV and HDV testing

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

Quantitative HAV RNA (viral load) is not reimbursable.

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

Quantitative HDV RNA (viral load) is not reimbursable.

inv-06: Reimbursable and restricted viral hepatitis testing

Covered testing circumstances (as revised across updates):

HCV nucleic acid testing reimbursable situations

Situations: a) As a follow-up for individuals who test positive by initial HCV antibody screening (to differentiate active versus resolved infection); b) One-time screening for perinatally exposed infants who are 2-6 months of age (revised from 2-17 months).
revised from 2-17 months

HCV antibody testing frequency for high-risk: Antibody testing for HCV once every three months may be reimbursable for individuals with ongoing risk factors while risk factors persist (includes individuals receiving immunosuppressant therapy and immunocompromised individuals as noted in policy updates).every 3 months

applies while risk persists

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

Quantitative nucleic acid testing for hepatitis A viral load and for hepatitis D viral load is not reimbursable. The policy specifies that while IgM anti-HAV or qualitative HAV RNA testing may be reimbursable for symptomatic individuals who test negative for HBV and HCV, and anti-HDV or qualitative HDV RNA testing may be reimbursable for individuals positive for HBV, quantitative nucleic acid assays to measure HAV or HDV viral load are explicitly excluded from reimbursement.

The policy update clarifies that quantitative nucleic acid testing for HAV and HDV viral load is not reimbursable. This language was added in the revision history to distinguish permitted qualitative or antibody testing from non-reimbursable quantitative viral load assays for HAV and HDV.

Per the most recent policy revision, quantitative nucleic acid testing for HAV and HDV viral load is explicitly non-reimbursable. The update added specific hepatitis A and D testing language to the reimbursement information, confirming that only IgM/qualitative HAV testing and anti-HDV/qualitative HDV RNA testing may be considered in defined clinical situations.

Covered Indications and Specific Situations

inv-25: Screening, diagnostic follow-up, and monitoring for HBV, HCV, HAV, and HDV per listed high-risk groups, exposures, treatment timing, and clinical presentation.

Screening, diagnostic follow-up, and monitoring may be reimbursable when the following covered indications are met:

HBV screening and follow-up: HBV triple panel screening, follow-up IgM anti-HBc, anti-HBs for seroconversion, and HBV DNA testing for select individuals (e.g., those undergoing immunosuppressive therapy) as described in HBV criteria.

See HBV Screening Criteria block for detailed high-risk situations

HCV follow-up nucleic acid testing: Qualitative HCV nucleic acid testing as follow-up after a positive HCV antibody screen to differentiate active versus resolved infection.

Used to differentiate active versus resolved infection

Perinatal HCV nucleic acid screening (infants): One-time qualitative HCV nucleic acid testing for perinatally exposed infants aged 2-6 months.

Frequency Limits and Testing Intervals

inv-30: HBV triple panel for individuals >=18 years — once per lifetime

TestHBsAg, anti-HBs, anti-HBc (HBV triple panel)

PopulationAll individuals 18 years of age and older

FrequencyOnce per lifetime

When reimbursableRoutine one-time screening; annual triple-panel screening may be reimbursable for asymptomatic, non-pregnant individuals meeting listed high‑risk situations

inv-31: HCV antibody for individuals >=18 years — once per lifetime

TestHCV antibody (anti-HCV)

Population

Coding and Reimbursement Codes

Procedure Codes (document states list exists but not included here)mixed

No codes listed

Added/updated laboratory codesmixed

86692	added to policy (description in document not provided)
86708	added to policy (description in document not provided)
86709	added to policy (description in document not provided)
87380	added to policy (description in document not provided)
87523	added to policy (description in document not provided)
87516	added to policy (description in document not provided)
87799	added to policy (description in document not provided)
G0567	added to policy (description in document not provided)

inv-12: Geographic HBV prevalence — >= 2%

DefinitionGeographic HBV prevalence threshold

Value>= 2%

UseApplied to determine eligibility for HBV triple-panel screening for individuals born in or who have traveled to high-prevalence regions or U.S.-born with parents from such regions

inv-13: Perinatal HCV screening age window — 2-6 months (updated from 2-17 months)

IndicationOne-time HCV nucleic acid screening for perinatally exposed infants

Age window2-6 months

Provider Actions, Billing, and Documentation

Note

Description

The Plan has implemented certain lab management reimbursement criteria. Not all requirements apply to each product; providers should review member plan documents and benefit specifics for prior-authorization or coverage requirements before ordering or billing services.

Check member plan for prior-authorization or other coverage requirements — Not all lab management reimbursement criteria apply to every product; providers should review plan documents (Certificates of Coverage, benefit booklets, Summary Plan Descriptions) and provider contract language for eligible coverage for services rendered.
Providers are responsible for submission of accurate documentation and coding — Claims must be submitted using valid HIPAA-approved code sets and appropriate code combinations per industry-standard coding guidelines (e.g., AMA CPT, HCPCS, ICD-10-CM/PCS, NDCs, CMS NCCI edits). Providers should retain supporting clinical documentation and submit additional documentation upon request. Claims are subject to plan documents, provider contract language, medical policies, clinical payment and coding policies, and code edit protocols; claim denials or adjustments may result if documentation or coding is incomplete or inconsistent.

Ordering Requirements

Prior Authorization

Verify plan-specific applicability and ordering requirements

Providers must check member plan documents for product-specific applicability and coverage before ordering tests and are responsible for accurate documentation and coding when placing orders.

Verify member eligibility and any prior-authorization requirements in plan documents before sending samples or billing.

Note

Order only for listed reimbursable clinical situations; no provider-type ordering restrictions specified

Order tests only for the clinical situations enumerated in the policy; the updates list the specific reimbursable situations (screening, follow-up, monitoring) but the policy does not impose explicit provider-type restrictions for ordering.

Ensure the ordered test corresponds to a reimbursable situation described in the policy (e.g., follow-up qualitative HCV NAT after a positive antibody; one-time perinatal HCV NAT at 2–6 months).

Services Not Covered

Not covered: Quantitative nucleic acid testing for HAV and HDV viral load is not reimbursable. The policy allows reimbursement for IgM anti-HAV or qualitative HAV RNA in symptomatic individuals (when HBV and HCV are negative) and for anti-HDV or qualitative HDV RNA in individuals positive for HBV, but excludes quantitative viral load testing for both HAV and HDV.

Not covered: The policy update history states that quantitative nucleic acid testing for HAV and HDV viral load is not reimbursable. This clarification was added during the documented policy revisions to delineate reimbursable qualitative/antibody testing from non-reimbursable quantitative viral load assays.

Background

This policy summarizes reimbursable hepatitis testing strategies for hepatitis B, C, A, and D, covering screening, confirmatory, and monitoring tests. It specifies one-time lifetime screening recommendations for HBV and HCV antibodies in adults, recurrent testing intervals for individuals with ongoing risk (e.g., every 3 months for select high-risk groups), indications for qualitative HCV nucleic acid testing and quantitative HCV viral load monitoring related to antiviral therapy, and testing approaches for HAV and HDV. For HAV and HDV the policy permits IgM anti-HAV or qualitative HAV RNA for symptomatic patients and anti-HDV or qualitative HDV RNA for those with HBV, but it explicitly states that quantitative nucleic acid testing for HAV and HDV viral load is not reimbursable.

Definitions and Abbreviations

inv-23: HBsAg, anti-HBs, anti-HBc — HBV triple panel

Panel componentsHepatitis B surface antigen (HBsAg); hepatitis B surface antibody (anti-HBs); total antibody to hepatitis B core antigen (anti-HBc)

Common nameHBV triple panel

Primary useOne-time adult screening and annual screening for asymptomatic non‑pregnant individuals meeting high‑risk criteria

Related guidanceApplied when geographic prevalence >=2% or other listed high‑risk situations are present

inv-24: Nucleic acid testing for HCV — HCV nucleic acid testing

Test typesQualitative nucleic acid testing (NAT) and quantitative NAT (viral load) distinctions for HCV

Revision History and Policy Changes

2025-07-25material_revisionLatest

Reimbursement information updated: clarified qualitative HCV nucleic acid testing situations; perinatal screening window changed to 2-6 months; added hepatitis A and D testing language clarifying qualitative vs quantitative testing and that quantitative HAV/HDV viral load testing is not reimbursable; added multiple CPT/HCPCS codes (86692, 86708, 86709, 87380, 87523, 87516, 87799, and G0567); clarified quarterly HCV antibody testing for immunosuppressed/immunocompromised individuals.

2025-01-15revision

Document updated with literature review; edited Reimbursement Information #9 to include the word 'qualitative' for HCV nucleic acid testing and shortened the perinatal screening age range based on CDC updates.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyHepatitis Testing

Policy CodePolicy CPCPLABO15

Change TypeMaterial updates to testing indications, frequencies, and code list

Effective DateNov 7, 2025

Next Review Date

Key ActionCheck member plan documents for product-specific coverage and reference this policy when billing the newly appended laboratory codes.

SourceLink

On This Page

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

Age window revised from prior broader range

HAV testing for symptomatic individuals: IgM anti-HAV or qualitative HAV RNA testing for symptomatic individuals who test negative for HBV and HCV.

Quantitative HAV RNA is not reimbursable

HDV testing for HBV-positive individuals: Anti-HDV or qualitative HDV RNA testing for individuals who test positive for HBV.

Quantitative HDV RNA is not reimbursable

inv-26: Follow-up HCV nucleic acid testing after positive antibody screening

Follow-up HCV nucleic acid testing after positive antibody screening — used to differentiate active versus resolved infection

HCV follow-up NAT: Qualitative HCV nucleic acid testing reimbursable as a follow-up for individuals who test positive by initial HCV antibody screening to determine active versus resolved infection.

inv-27: One-time HCV nucleic acid screening for perinatally exposed infants aged 2-6 months

One-time HCV nucleic acid screening for perinatally exposed infants

Perinatal HCV NAT (infants): One-time qualitative HCV nucleic acid testing reimbursable for infants perinatally exposed to HCV when performed at age 2-6 months.age 2-6 months

Age window revised from prior 2-17 months in earlier policy versions

inv-28: IgM anti-HAV or qualitative HAV RNA for symptomatic individuals who test negative for HBV and HCV.

IgM anti-HAV or qualitative HAV RNA for symptomatic individuals who test negative for 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 or qualitative HAV RNA testing may be reimbursable.

Quantitative HAV RNA is not reimbursable.

inv-29: Anti-HDV or qualitative HDV RNA testing for individuals positive for HBV

Anti-HDV or qualitative HDV RNA testing for individuals positive for HBV

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

Quantitative HDV RNA is not reimbursable.

All individuals 18 years of age and older

FrequencyOnce per lifetime

NotesOne-time and post-exposure testing reimbursable for listed recognized conditions or exposures

inv-32: HCV antibody for ongoing-risk individuals — every 3 months while risk persists

TestHCV antibody (anti-HCV)

PopulationIndividuals with ongoing risk factors (e.g., ongoing hemodialysis, current injection drug use with shared equipment, high‑risk sexual behavior)

FrequencyEvery 3 months while risk persists

ApplicationApplies only while the documented risk factors persist

inv-33: HCV antibody — Antibody testing for HCV once every three months

Policy statementAntibody testing for HCV once every three months may be reimbursable for individuals with ongoing risk factors while risk factors persist

Examples of ongoing riskOngoing hemodialysis; current injection drug use with shared needles/equipment; high‑risk sexual behavior; individuals receiving immunosuppressant therapy; immunocompromised individuals

Frequency noteTesting allowed quarterly only while documented risk persists

Revised from prior range of 2-17 months per policy update

PurposeDetect active infection in perinatally exposed infants using qualitative NAT

Billing Rule

Provider Actions — Billing & Documentation

Policy reimbursement and billing details have been updated; providers should reference the policy when billing and ensure accurate use of the reimbursable codes listed in the policy.

Reimbursable codes and billing note — Providers should bill only for tests and codes that meet the reimbursement criteria and are supported by medical record documentation. Newly added or revised codes in recent updates include 86692, 86708, 86709, 87380, 87523, 87516, 87799, and G0567; verify the policy's code table for full lists and status.
Coding and documentation subject to review — All billed services and codes are subject to review against benefit coverage, provider contracts, clinical payment and coding policies, and automated code-edit logic. When requested, providers must submit clinical documentation (e.g., signs/symptoms, test results, indication for testing, relevant risk factors, immunosuppression status) to support reimbursement.
Documentation for HAV/HDV testing — Hepatitis A: IgM anti-HAV or qualitative HAV RNA testing may be reimbursable for individuals with signs and symptoms of acute viral hepatitis who have tested negative for HBV and HCV; quantitative HAV viral load testing is not reimbursable. Hepatitis D: For individuals who have tested positive for HBV, testing for HDV antibody (anti-HDV) or qualitative HDV RNA may be reimbursable; quantitative HDV viral load testing is not reimbursable.

Prior Authorization

Provider Action — Policy Updates

Providers should highlight updated provider actions and billing responsibilities associated with recent policy changes and ensure processes are updated to reflect new code additions and testing-specific reimbursement rules.

Provider action (update-specific) — Review and implement recent updates affecting reimbursement and billing workflows, especially additions for HAV/HDV testing language and new reimbursable codes.
Non-reimbursable viral load testing for HAV/HDV — Quantitative nucleic acid testing for HAV and HDV viral load is not reimbursable; do not bill quantitative viral load CPT codes for HAV or HDV.

When qualitative NAT is reimbursableAs follow-up to a positive HCV antibody to differentiate active vs resolved infection; for immunocompromised individuals; one-time screening of perinatally exposed infants aged 2-6 months

When quantitative NAT is reimbursableQuantitative HCV viral load reimbursable prior to DAA initiation, after 4 weeks of therapy, at end of treatment, and at 12, 24, and 48 weeks post‑treatment

PurposeQualitative NAT establishes active infection when antibody positive; quantitative NAT used for treatment monitoring and response assessment

2024-03-15revision

Reimbursement Information #9 was revised (document updated with literature review).

2024-02-01addition

Added Hepatitis B header and new lifetime triple testing statement for adults; combined and clarified several high-risk criteria in reimbursement information.

2023-11-01revision

Document updated with literature review; reimbursement information revised to add new statements and clarifications including timing language (e.g., 48 weeks) and note additions.