CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLABOS1

Diagnostic Testing of Common Sexually Transmitted Infections

This reimbursement/payment policy governs BCBSOK coverage and lab management reimbursement criteria for testing of common STIs (syphilis, chlamydia, gonorrhea, HSV, HPV, Trichomonas) and applies to providers submitting claims to Blue Cross Blue Shield - Oklahoma.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyDiagnostic Testing of Common Sexually Transmitted Infections

Policy CodePolicy CPCPLABOS1

Change TypeNew policy (no material changes since creation)

Effective DateNov 1, 2022

Next Review DateN/A

Key ActionProviders must submit accurate documentation and code claims using HIPAA-approved code sets; claims are subject to review and may require additional documentation upon request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2022-11-01policy effective date

C, N, T, T.v, HSV, HPVpathogens covered

multiplereimbursable code list

syphilis NAAT/PCRnot reimbursable example

2014-2021

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.

Reimbursement / Coverage Criteria

STI testing reimbursement criteria

Reimbursement criteria for STI testing are specified by pathogen and clinical context. Covered when the listed conditions for each pathogen are met:

Syphilis (treponemal and nontreponemal)

Asymptomatic person in a high-risk category: once a year assessment using either a 'standard' or 'reverse' algorithm that includes initial and confirmatory tests (e.g., treponemal Ig test AND nontreponemal test).
HIV-positive men or men who have sex with men (MSM): testing once every three months.
As part of pregnancy screening.
Diagnosis for any person presenting with signs and/or symptoms of syphilis.
A nontreponemal test may be reimbursable as a test-of-cure following treatment of a positive syphilis infection.
Testing for syphilis using PCR or NAAT is not reimbursable.
PCR/NAAT explicitly excluded.

Chlamydia (NAAT)

Asymptomatic person in a high-risk category: once a year NAAT screening.
As part of pregnancy screening.
Diagnosis for any person presenting with signs and/or symptoms of chlamydial infection.
Test-of-cure reimbursable at least three months after initial chlamydial diagnosis.
Diagnosis of suspected lymphogranuloma venereum (LGV).
Serology testing for chlamydia or LGV is not reimbursable.

Gonorrhea (NAAT and culture)

Asymptomatic person in a high-risk category: once a year NAAT screening.
As part of pregnancy screening.
Diagnosis for any person presenting with signs and/or symptoms of gonorrheal infection.
NAAT may be reimbursable as test-of-cure.
Culture testing may be reimbursable for antimicrobial susceptibility if patient does not respond to initial treatment.

Herpes Simplex (HSV PCR/NAAT and serology)

NAAT/PCR reimbursable for patients with active genital ulcers or mucocutaneous lesions.
Type-specific HSV-2 serologic testing (gG2) may be reimbursable for: recurrent/atypical genital symptoms with negative PCR/culture; clinical diagnosis with negative PCR/culture or without laboratory confirmation; or when patient's partner has genital herpes.
General serologic screening in asymptomatic patients is not reimbursable.
Nonspecific immunoassay HSV tests are not reimbursable.

Human Papillomavirus (HPV)

Reimbursable when performed as part of cervical cancer screening per the Cervical Cancer Screening policy (CPCPLABOO2).
Reimbursable for immunohistochemistry (e.g., p16) or NAAT testing for HPV, including high-risk types (HPV-16, HPV-18), in the diagnosis or assessment of cancer or cancer therapy.
Screening for oncogenic high-risk HPV types as part of a general STI/STI panel for asymptomatic patients is not reimbursable.

Trichomonas vaginalis

NAAT/PCR reimbursable for symptomatic individuals.
NAAT/PCR reimbursable for certain asymptomatic high-risk groups (including individuals in high-prevalence settings such as STI clinics and individuals who exchange sex for payment).
Rapid enzyme immunoassay identification is not reimbursable.

Quantitative nucleic acid testing

Using nucleic acid testing to quantify organisms (C. trachomatis, N. gonorrhoeae, HSV-1, HSV-2, HPV, T. pallidum, T. vaginalis) is not reimbursable.

PrEP-related testing

Baseline: confirm negative HIV antibody; baseline renal function (serum creatinine and estimated creatinine clearance); pregnancy test; HBV and HCV status as indicated.
During PrEP: HIV antibody testing once every three months; renal function three months after initiation and then up to every six months; NAAT screening for gonorrhea and chlamydia based on anatomic site of exposure and/or syphilis blood test once every three months for MSM and for women with reproductive potential; sexually active individuals: once at nine months after PrEP initiation and then once every six months thereafter; pregnancy test every three months.
Nucleic acid testing to quantify organisms is not reimbursable in the context of PrEP monitoring (see quantitative testing exclusions).

Screening exclusions for low-risk asymptomatic individuals

Screening of asymptomatic individuals NOT in high-risk categories is not reimbursable except when: part of newborn screening, part of pregnancy screening, or follow-up of a victim of sexual assault (applies across syphilis, chlamydia, gonorrhea).

Scope note: Policy is limited to testing for C. trachomatis, N. gonorrhoeae, T. pallidum, T. vaginalis, HSV, and HPV. Other related testing guidance is found in referenced policies (e.g., prenatal, cervical cancer screening, pathogen panel testing).

Policy update

Policy status and update history:

Policy created 11/1/2022 as a new policy (Policy Update History: 11/1/2022, 1 = New policy).

This excerpt indicates creation date; no subsequent revisions are listed in this segment.

Procedure Codes and Testing Frequency

Selected lab and molecular test codesmixed

82565
82575
84702
84703
86592
86593
86631
86632
86694
86695

1–10 of 48

1/5

Referenced diagnostic categoriesmixed

No codes listed

Syphilis testing frequency for HIV-positive men or MSM (inv-05)

Recommended frequencyOnce every 3 months for HIV-positive men or men who have sex with men (MSM)

ContextApplied as part of PrEP-related and routine screening for sexually active MSM

Related testsBlood test for syphilis (treponemal and nontreponemal) or NAAT guidance when applicable

Syphilis annual screening for asymptomatic high-risk persons (inv-06)

Recommended frequencyOnce a year for asymptomatic persons in a high-risk category

Testing algorithm

Documentation, Billing, and Submission Requirements

Documentation Required

Documentation and claim submission requirements

Providers are responsible for submitting accurate documentation of services performed and must submit claims using valid code combinations from HIPAA‑approved code sets (for example CPT, HCPCS, ICD‑10, NDC). Claims are subject to code‑edit protocols and review against benefit coverage, provider contract language, medical and payment/coding policies. Upon request, providers must submit additional supporting documentation.

Use HIPAA‑approved code sets (CPT, HCPCS, ICD‑10, NDC, etc.) and follow industry coding guidelines (AMA CPT, UB, CMS NCCI/CCI, DRG guidance).
Claims are subject to code edit protocols and review; provide additional documentation upon request.

Note

Policy creation notice

This policy was created effective 11/1/2022 as a new policy; reimbursement rules and any required provider prior authorization, documentation, or billing processes are defined in the policy.

Policy creation date: 11/1/2022 (New policy).

Definitions and Reference Notes

High-risk (syphilis) — definition and criteria (inv-11)

Definition (summary)Individuals at increased risk for syphilis based on behavior, status, or setting

Included criteriaSexually active men who have sex with men (MSM); sexually active persons with HIV-positive status; exchanging sex for money or drugs; having a sexual partner recently diagnosed with an STI; individuals in adult correctional facilities

Pregnancy-specific risk factorsDuring pregnancy: HIV-positive status, drug use or transactional sex, multiple partners, late or no prenatal care, methamphetamine or heroin use, incarceration of woman or partner, unstable housing or homelessness

High-risk (chlamydia/gonorrhea) — definition and criteria (inv-12)

Definition (summary)Individuals at increased risk for chlamydia and/or gonorrhea based on age, behavior, partners, or history