DraftBlue Cross Blue Shield - OklahomaPolicy CPCPLAB057

Coronavirus Testing in the Outpatient Setting

Reimbursement and coding guidance for outpatient SARS-CoV-2 testing (nucleic acid, antigen, and serology) and related coronaviruses for Blue Cross and Blue Shield of Oklahoma; describes when tests may be reimbursable and tests that are not reimbursable.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyCoronavirus Testing in the Outpatient Setting

Policy CodePolicy CPCPLAB057

Change TypeRevisions to reimbursement language and coding deletions

Effective DateNovember 7, 2025

Next Review DateN/A

Key ActionSubmit claims using valid HIPAA-approved code sets and be prepared to provide additional documentation upon request.

SourceLink

POLICY UPDATE CHANGES

Edited reimbursement information to remove duplicative language and clarify test situations, and removed certain CPT/HCPCS codes.

Added rapid molecular tests as an acceptable testing option and added NAAT as acceptable for MIS-A and MIS-C.

Removed items (e.g., #6, #7, #8, #9) that are addressed in separate pathogen panel testing policy (CPCPLAB045) and removed genotyping item.

Removed multiple test and telehealth codes across prior updates (examples include G2023, G2024, U0003-U0005, and later 86790, 87631-87633, 87797, 87799, 0115U, 0202U, 0223U, 0225U, C9803).

1.0version

11/07/2025plan effective

07/25/2025

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.

01/23/2025prior edit

multipleexplicit exclusions

Outpatient Coronavirus Testing Coverage Criteria

inv-01: Outpatient coronavirus testing coverage criteria — Reimbursable testing scenarios and exclusions

Reimbursable testing scenarios and exclusions

Reimbursable when the following rules are applied as described below:

Targeted nucleic acid testing (RT-PCR or rapid molecular)

For individuals displaying signs and symptoms of possible COVID-19 infection (see NOTE 2 for examples of signs/symptoms).
For asymptomatic individuals with known exposure to COVID-19, EXCEPT when the individual has had a previous COVID-19 infection within the last 90 days.

Nucleic acid testing for SARS and MERS

For individuals with signs or symptoms of SARS who have traveled to endemic areas or been exposed to persons with SARS, targeted nucleic acid testing (e.g., RT-PCR) may be reimbursable.
For individuals with signs or symptoms of MERS who have traveled to endemic areas or been exposed to persons with MERS, targeted nucleic acid testing (e.g., RT-PCR) may be reimbursable.

Testing to support specific syndromic diagnoses

To support a diagnosis of multisystem inflammatory syndrome in children (MIS-C), multisystem inflammatory syndrome in adults (MIS-A), or post-acute sequelae of SARS-CoV-2 infection (PASC), nucleic acid amplification testing AND host antibody serology testing may be reimbursable when clinically indicated.

Antigen testing frequency for symptomatic individuals

For symptomatic individuals, antigen-detecting diagnostic tests (e.g., antigen rapid tests) may be reimbursable once every 48 hours.

Exclusions

Antibody testing for SARS-CoV-2 provided under an FDA Emergency Use Authorization during a public health emergency is NOT addressed by this policy (NOTE 1).
For all other situations not described above, host antibody serology testing is not reimbursable.
Neutralization antibody testing for SARS-CoV-2 is not reimbursable in any situation.
Testing for other endemic coronaviruses (229E, NL63, OC43, HKU1) is not reimbursable.

inv-02: Reimbursement and coding changes (summary) — summary of reimbursement revisions, acceptable test types, frequency changes, and policy history

Summary of reimbursement revisions and policy history

Policy update history and summary of material changes are listed below.

Acceptable test types

Rapid molecular tests/NAAT were added as acceptable options for targeted nucleic acid testing; wording was later edited to remove duplicative phrasing (e.g., removal of 'including rapid molecular tests') and clarified by adding 'any of' to applicable situations.

Testing frequency changes

Antigen testing frequency guidance updated to specify reimbursement of antigen-detecting diagnostic tests for symptomatic individuals once every 48 hours (noted in the 01/23/2025 update and reflected thereafter).

Delegation of panel items

Procedure Codes and Coding Guidance

Procedure codesmixed

Procedure codes referenced — list not exhaustive; inclusion does not guarantee coverage.

Examples of codes added/removed in updatesCPT | HCPCS | Modifier | mixed

86318	Removed from policy
87428	Removed from policy
0408U	Added on 03/01/2024

Older codes removedmixed

G2023	Removed previously
G2024	Removed previously
U0003	Removed previously
U0004	Removed previously
U0005	Removed previously

inv-06: Antigen test frequency for symptomatic individuals — once every 48 hours

Antigen test frequencyAntigen-detecting diagnostic tests for symptomatic individuals are reimbursable once every 48 hours.

ApplicabilityApplies to antigen rapid tests for individuals displaying signs and symptoms of possible COVID-19 infection (see NOTE 2).

Policy referenceListed as item 5 in Reimbursement Information (chunk 3).

inv-07: Prior COVID-19 infection window for asymptomatic exposed individuals — not reimbursable if previous infection within last 90 days

Prior infection windowTesting for asymptomatic individuals with known exposure is NOT reimbursable when the individual had a prior COVID-19 infection within the last 90 days.

Documentation, Claims, and Reimbursement Actions for Providers

Documentation Required

Documentation and claims review

Providers are responsible for submission of accurate documentation of services performed. Claims are subject to claim review against benefit coverage, provider contracts, medical policies, clinical payment and coding policies, and coding software logic; upon request, providers must submit any additional documentation requested by the plan.

Submit accurate documentation of services performed.
Be prepared to provide additional documentation upon request for claim review against plan documents, contracts, and policies.

Billing Rule

Coding and claim submission requirement

Claims must be coded using valid HIPAA-approved code sets and industry coding guidelines (including CPT, HCPCS, ICD-10, NDCs, CCI rules, and other standard guidance). Claim submissions are subject to code edit protocols and coding software logic.

Test Types and Definitions

inv-12: Targeted nucleic acid testing — RT-PCR and rapid molecular tests, NAAT for MIS-A/C, applicability notes

Accepted test typesTargeted nucleic acid testing includes RT-PCR and rapid molecular tests (NAATs); these may be reimbursable for symptomatic individuals and other specified situations.

Use for MIS-A/MIS-CNAAT is explicitly noted as an acceptable test option to support diagnosis of MIS-A and MIS-C (policy updates, chunk 31).

Applicability notesMay be reimbursable for symptomatic individuals, asymptomatic exposed individuals (with exceptions), and for travel/exposure-related SARS or MERS testing (chunk 3).

inv-13: Antigen-detecting diagnostic tests — antigen rapid tests for symptomatic individuals; reimbursement frequency limitation

Test typeAntigen-detecting diagnostic tests (e.g., antigen rapid tests) are the antigen option referenced for symptomatic individuals.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyCoronavirus Testing in the Outpatient Setting

Policy CodePolicy CPCPLAB057

Change TypeRevisions to reimbursement language and coding deletions

Effective DateNovember 7, 2025

Next Review DateN/A

Key ActionSubmit claims using valid HIPAA-approved code sets and be prepared to provide additional documentation upon request.

SourceLink

On This Page

Several items related to pathogen panels were removed from this policy and delegated to CPCPLAB045 (Pathogen Panel Testing); Note 5 was deleted as part of these edits.

Coding and reimbursement edits

Multiple CPT/HCPCS and other codes were removed across updates (examples listed in the history). Code 0408U was added on 03/01/2024; codes such as 86318 and 87428 were removed in later edits, and numerous other codes were removed in prior updates.

Document history

Key revision dates: 11/01/2022 (origination), 11/01/2023, 03/01/2024 (added 0408U), 03/15/2024 (literature review; codes removed), 01/23/2025 (added rapid molecular tests, updated antigen frequency, NAAT for MIS-A/MIS-C), and 07/25/2025 effective with summary noting deletions and clarifications; Summary of Revisions shows effective date 11/07/2025 for the latest document update.

ContextThis exception is specified within the targeted nucleic acid testing reimbursement criteria for asymptomatic exposed individuals (chunk 3).

Related noteSee Reimbursement Information item 1.b for the exception language.

inv-08: testing frequency — once every 48 hours referenced in 01/23/2025 update

Updated frequency referenceThe 01/23/2025 policy update amended reimbursement guidance to include a once-every-48-hour frequency for antigen testing.

Change log locationDocument Policy Update History (01/23/2025 entry) notes update to #5 to include once every 48 hour frequency (chunk 31).

Resulting guidanceFrequency guidance subsequently appears in Reimbursement Information as item 5 (chunk 3) after updates and edits.

Use HIPAA-approved code sets and industry standard coding guidelines (CPT, HCPCS, ICD-10, NDC, DRG, CCI, etc.).
Expect claims to be processed against code edit protocols and coding software logic.

Billing Rule

Reimbursement edits and cross-policy referral

The policy history documents revisions to reimbursement guidance and removal of specific procedure codes; some items were removed and delegated to CPCPLAB045 (Pathogen Panel Testing). Providers should note deleted codes and cross-reference CPCPLAB045 for panel testing guidance.

Review the Policy Update History for removed codes (e.g., deletion of 86318 and 87428; earlier removals such as G2023, G2024, U0003–U0005, and others).
Cross-reference CPCPLAB045 for items moved from this policy (Pathogen Panel Testing).

Reimbursement frequency limitReimbursable once every 48 hours for symptomatic individuals as specified in item 5 (chunk 3); update to include this frequency is recorded in the 01/23/2025 history (chunk 31).

ScopeIntended for individuals displaying signs and symptoms of possible COVID-19 infection (see NOTE 2 for symptom examples).

inv-14: Host antibody serology and neutralization testing — serology reimbursable only for specific diagnoses; neutralization antibody testing not reimbursable

Serology reimbursement scopeHost antibody serology testing may be reimbursable to support diagnosis of MIS-C, MIS-A, or PASC when clinically indicated.

General exclusion for serologyHost antibody serology testing is not reimbursable for situations not described in the reimbursable criteria (item 6, chunk 3).

Neutralization testingNeutralization antibody testing for SARS-CoV-2 is not reimbursable in any situation (item 7, chunk 3).

inv-15: Bibliographic references supporting test performance, EUA summaries, multiplex assays, sequencing, sample pooling, and guidance

EUA summaries and FDA resourcesPolicy references FDA EUA summaries and device listings relevant to antigen and molecular assays (multiple FDA links cited in chunks 18, 20, 24, 30).

Performance and evaluation studiesIncludes peer-reviewed evaluations of antigen and molecular test performance and diagnostic accuracy (chunks 19, 20, 21).

Sequencing and multiplex assaysReferences whole-genome sequencing guidance and multiplex assay documentation (chunks 22, 23, 20).

Public health and society guidanceCites CDC, WHO, IDSA, ECDC, AAP, and specialty society guidance relevant to testing strategies and MIS-C/MIS-A definitions (chunks 24, 26, 27, 28, 29).