CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLAB016

Cpcplab016 Pediatric Preventive Screening 01 15 25

Defines laboratory-based preventive screening reimbursement criteria for individuals newborn through age 18 (excluding newborn genetic disorder screening) for Blue Cross Blue Shield of Oklahoma products; notes product-specific applicability and directs providers to related policies for specific tests.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyCpcplab016 Pediatric Preventive Screening 01 15 25

Policy CodePolicy CPCPLAB016

Change TypeRevised (04/29/2024)

Effective DateJan 15, 2025

Next Review Date

Key ActionEnsure newborn screening panels comply with applicable federal and state law recommendations and maintain documentation supporting adherence.

SourceLink

POLICY UPDATE CHANGES

04/29/2024, Effective Date; Document updated with literature review. Reimbursement information revised for clarity. References revised.

11/01/2023: Document updated with literature review; reimbursement information revised; dyslipidemia screening ages 17-21 moved to CPCPLAB020; STI screening moved to CPCPLAB051; annual Hepatitis B screening moved to CPPLAB015.

11/01/2022: New policy created.

7Screening categories listed

18Age upper bound for policy

1Policy version

Policy Title: Pediatric Preventive Screening (Policy Number: CPCPLAB016). This Blue Cross Blue Shield of Oklahoma policy defines laboratory-based preventive screening reimbursement criteria for individuals newborn through age 18. It is product-specific—not all requirements apply to each product—so providers should review plan documents for coverage determinations. Plan effective date: 01/15/2025; Policy approval/last review: 04/29/2024. Related policies for specific pediatric testing include CPCPLAB051 (Diagnostic Testing of Common Sexually Transmitted Infections), CPCPLAB004 (Diabetes Mellitus Testing), CPCPLAB019 (Thyroid Disease Testing), CPCPLAB020 (Cardiovascular Disease Risk Assessment), and CPCPLAB065 (Human Immunodeficiency Virus).

Reimbursable Pediatric Preventive Screening Tests

The following screenings may be reimbursable when applicable (age- and risk-based criteria specified):

ALL of the following

Newborn screening panel may be reimbursable when it follows all applicable federal and state law recommendations.
Hyperbilirubinemia screening: Screening for hyperbilirubinemia in all newborns may be reimbursable.
Congenital hypothyroidism screening: Screening for congenital hypothyroidism in all newborns utilizing serum thyroxine (T4) and/or thyroid-stimulating hormone (TSH) may be reimbursable.
Sickle cell disease screening: Screening for sickle cell disease in all newborns may be reimbursable.
Blood lead screening reimbursable for any of:
- Blood lead: routine age: For individuals ages 12 months to 2 years12 months to 2 years
- Blood lead: at-risk age: For individuals ages 6 months to 6 years who are at increased risk for lead exposure6 months to 6 years (if at increased risk)
  See Note 1 for risk factors
Anemia screening reimbursable for any of:
- Anemia: routine age: For all individuals 12 months of age12 months
- Anemia: at-risk age: For individuals 4 months and older who are at risk for iron deficiency>= 4 months (if at risk for iron deficiency)
  See Note 2 for risk factors
Tuberculosis screening when at risk: For individuals 1 month of age or older who are at increased risk of contracting tuberculosis, tuberculosis screening may be reimbursable.>= 1 month (if at increased TB risk)
See Note 3 for TB risk factors
Screening for dyslipidemia reimbursable in any of:
- Dyslipidemia: annual at-risk: Annually for children and adolescents who are at increased risk due to personal history or family historyannual (if at increased risk)
  See Note 4 for dyslipidemia risk factors
- Dyslipidemia: universal age windows: Once for all children and adolescents during each of the age periods: 9-11 years and 17 yearsOnce at ages 9-11 and once at 17 years

Not Covered / Experimental

Note: This policy excludes newborn screening for genetic disorders (see scope and Reimbursement Information). For certain tests and screenings (for example, sexually transmitted infection testing, dyslipidemia in some age ranges, or annual hepatitis B screening) operational responsibility or guidance has been reassigned to related policies listed above; providers should check the referenced related policies and their product-specific plan documents for coverage details and exclusions.

Provider Actions and Documentation Requirements

Documentation Required

Follow federal/state newborn screening recommendations

Ensure newborn screening panels comply with applicable federal and state law recommendations and maintain documentation supporting adherence.

Documentation Required

Risk assessment documentation for lead/iron/TB/dyslipidemia

Document risk factors (per Notes 1-4) in the medical record to justify screening outside universal age windows.

Billing Rule

Use valid code combinations and standard code sets

Submit claims using HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC) and follow industry coding guidelines; claims subject to code edit protocols and review.

Documentation Required

Provide additional documentation upon request

Upon request, submit additional documentation to support medical necessity and coverage per plan documents and provider contract.

Background and Guidelines Referenced

Background: BCBSOK has implemented laboratory management reimbursement criteria for preventive pediatric screening tests for individuals newborn through age 18. The policy references guideline sources including the American Academy of Pediatrics (AAP), Centers for Disease Control and Prevention (CDC), and the U.S. Preventive Services Task Force (USPSTF). The policy notes that not all requirements apply to each product and providers should review their plan documents and provider contracts for coverage specifics and claim submission requirements.

Definitions: Adolescent — Defined per WHO as any person between the ages of 10 and 19.

Revision History

04/29/2024document updateLatest

Document updated with literature review; reimbursement information revised for clarity; references revised. Plan effective date noted as 01/15/2025.

11/01/2023material change

Document updated with literature review; reimbursement information revised. Operational reassignments: dyslipidemia screening for individuals ages 17-21 moved to CPCPLAB020; chlamydia, gonorrhea and/or syphilis screening moved to CPCPLAB051; annual Hepatitis B screening moved to CPPLAB015.

11/01/2022policy creation

New policy created (initial policy establishment).

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyCpcplab016 Pediatric Preventive Screening 01 15 25

Policy CodePolicy CPCPLAB016

Change TypeRevised (04/29/2024)

Effective DateJan 15, 2025

Next Review Date

Key ActionEnsure newborn screening panels comply with applicable federal and state law recommendations and maintain documentation supporting adherence.

SourceLink

On This Page

OpenPayer

Cpcplab016 Pediatric Preventive Screening 01 15 25

Coverage Summary

Reimbursable Pediatric Preventive Screening Tests

Not Covered / Experimental

Coding

Provider Actions and Documentation Requirements

Background and Guidelines Referenced

Revision History