CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLABO14

Prenatal Screening (Nongenetic)

Defines BCBSOK reimbursement criteria and coding guidance for routine nongenetic prenatal laboratory screening services for pregnant individuals; applies to providers submitting claims to Blue Cross Blue Shield of Oklahoma.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPrenatal Screening (Nongenetic)

Policy CodePolicy CPCPLABO14

Change TypeMaterial updates and removals (referencing other policies)inclusivity language edits

Effective DateNov 1, 2023

Next Review Date

Key ActionSubmit accurate documentation with claims and be prepared to provide additional documentation upon request; claims are subject to review against plan documents and policy guidance.

SourceLink

POLICY UPDATE CHANGES

Note referencing other BCBSOK policies for thyroid testing, fetal aneuploidy screening, and Zika/vector-borne infection testing was added.

Screening for fetal aneuploidy guidance was removed from this policy and moved to the fetal aneuploidy policy.

Prior instruction regarding thyroid dysfunction testing (item #5) was removed from this policy.

Stated that hCG testing is not reimbursable for normal uncomplicated pregnancies.

Language was revised to use 'individuals' instead of 'women' throughout for inclusivity.

~70codes listed (approx.)

24-28 weeksRh(D) repeat testing window

36-37 weeks

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GBS screening timing

24-<35 wksfetal fibronectin window

Reimbursable and Non-Reimbursable Prenatal Screening

Reimbursable routine prenatal screening

Routine prenatal screening that may be reimbursable for pregnant individuals includes the following when medically appropriate:

ALL of the following

ANY of the following
- Screening for HIV infection
- Screening for Chlamydia trachomatis infection
- Screening for Neisseria gonorrhea infection
- Screening for hepatitis B
- Screening for tuberculosis in pregnant individuals deemed to be at high risk for TB
Screening for type 2 diabetes at the first prenatal visit
Screening for gestational diabetes during gestational weeks 24–28 and at the first prenatal visit if risk factors are present24-28 weeks
Screening for bacteriuria; urinalysis and urine culture
Screening for anemia with a CBC or hemoglobin and hematocrit with mean corpuscular volume
Determination of blood type, Rh(D) status, and antibody status during the first prenatal visit
Repeat Rh(D) antibody testing for all unsensitized Rh(D)-negative individuals at 24 to 28 weeks' gestation, unless the biological father is known to be Rh(D)-negative24-28 weeks
Screening for Group B streptococcus once (recommended during gestational weeks 36–37 by ACOG)36-37 weeks
Testing for varicella immunity
Rubella antibody testing

Conditional and excluded tests

Specific reimbursable or non-reimbursable positions and conditional criteria:

ALL of the following

Rapid HIV
- Rapid HIV testing for pregnant individuals who present in active labor with an undocumented HIV status may be reimbursable
ALL of the following
- Individuals under 25 years of age
- Individuals with new or multiple sexual partners
- Individuals with a history of sexually transmitted infections (e.g., Bacterial Vaginosis, Chancroid, Chlamydia, Gonorrhea, Genital Herpes, Hepatitis B, Hepatitis C, HIV/AIDS, HPV, Lymphogranuloma Venereum, Syphilis, Trichomoniasis)

CPT / HCPCS / Procedure Coding Guidance

Example listed laboratory CPT/HCPCS codesmixed

80055	Obstetric panel
80081	Drug screen
81001	Urinalysis
85025	Complete blood count (CBC) automated
82962	Glucose tolerance test

Additional codes listed in source (not part of example group in brief)mixed

81002
81003
81007
81015
82677
82731
82947
82950
82951
83020

1–10 of 47

1/5

Code list completeness

Scope of code listThe listed CPT/HCPCS codes are examples and not an exhaustive or comprehensive code set for prenatal screening services.

Inclusion does not guarantee reimbursementPresence of a code on the list does not guarantee coverage or payment; reimbursement is subject to policy criteria and plan documents.

Use as reference onlyProviders should use the code list as a reference and verify coverage against specific policy criteria and member plan documents.

Additional codes possibleOther applicable codes may exist beyond those listed; billing should follow HIPAA-approved code sets and industry coding guidelines.

Documentation, Claim Review, and Coding Requirements

Billing Rule

Coding requirements

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. Claims should be coded appropriately according to industry-standard coding guidelines, including but not limited to: Uniform Billing (UB) Editor, American Medical Association (AMA) Current Procedural Terminology (CPT), CPT Assistant, Healthcare Common Procedure Coding System (HCPCS), ICD‑10‑CM and PCS, National Drug Codes (NDC), Diagnosis Related Group (DRG) guidelines, Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) Policy Manual, CCI table edits, and other CMS guidelines. Claims are subject to the code edit protocols for services/procedures billed and may be subject to automated and/or manual claim review.

Use HIPAA‑approved code sets and valid code combinations when submitting claims.
Follow industry-standard coding guidance (e.g., CPT, HCPCS, ICD‑10, NDC, DRG, NCCI/CCI).
Claims are subject to code edit protocols and may be reviewed for compliance with plan benefits, provider contract terms, medical policies, and coding policies.
Upon request, providers should submit any additional documentation to support the claim.

Definitions and Coding Expectations

Covered Services

DefinitionCovered Services are the health care services for which a member is entitled to benefits under their plan documents; plan documents govern in case of conflict with this policy.

Policy relationshipIf a CPCP conflicts with a plan document or provider contract, the plan document or contract will govern the member’s entitlement to Covered Services.

Documentation requirementProviders must submit accurate documentation for services rendered; claims are subject to review against plan coverage and policy criteria.

Coding expectations

Required code setsProviders are expected to submit claims using HIPAA‑approved code sets (for example, CPT, HCPCS, ICD‑10, NDC).

Industry coding guidelinesClaims should be coded according to industry standard coding guidelines including UB edits, AMA CPT guidance, DRG, and CMS NCCI/CCI edits.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPrenatal Screening (Nongenetic)

Policy CodePolicy CPCPLABO14

Change TypeMaterial updates and removals (referencing other policies)inclusivity language edits

Effective DateNov 1, 2023

Next Review Date

Key ActionSubmit accurate documentation with claims and be prepared to provide additional documentation upon request; claims are subject to review against plan documents and policy guidance.

SourceLink

On This Page

Individuals with past or current injection drug use

ALL of the following

Singleton or twin gestations
Intact membranes
Cervical dilation <3 cm<3 cm
The individual is experiencing symptoms suggestive of preterm labor between 24 and less than 35 weeks' gestation24 to <35 weeks

For individuals with a normal pregnancy without complications, human chorionic gonadotropin (hCG) hormone testing is not reimbursable

For all other situations not described above, FFN assays are not reimbursable

Serial monitoring of salivary estriol levels as a technique of risk assessment for preterm labor or delivery is not reimbursable

Documentation Required

Documentation and claim review

Providers must submit accurate documentation and may be asked to provide additional documentation to support medical necessity, coding, and billing. Claim submissions are subject to claim review, including review against plan benefits, provider contract language, medical policies, clinical payment and coding policies, and coding software logic. If a conflict arises between this Clinical Payment and Coding Policy and a member's plan document, the plan document governs. If a conflict arises between this policy and a provider contract, the provider contract governs. BCBSOK may use reasonable discretion in interpreting and applying this policy and has final discretionary authority to the extent provided under applicable plan documents.

Documentation may be requested during claim review — keep complete, legible records.
BCBSOK may interpret and apply this policy using reasonable discretion; plan documents or provider contracts govern in case of conflict.

Accurate codingClaims should use valid code combinations and be coded appropriately; claims are subject to code edit protocols and review.

Supporting documentationUpon request, providers are urged to submit additional documentation to support coding and payment determinations.