CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLAB026

Fecal Calprotectin Testing in Adults

Defines BCBSOK reimbursement stance for fecal calprotectin laboratory testing in adults, including when testing may be reimbursable and when it is not; applicable to providers submitting claims to Blue Cross Blue Shield - Oklahoma.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyFecal Calprotectin Testing in Adults

Policy CodePolicy CPCPLAB026

Change TypeNo material changes

Effective DateNov 1, 2023

Next Review DateN/A

Key ActionProviders must submit accurate documentation of services performed and provide additional documentation upon request; claims are subject to plan documents, provider contracts, medical policies, and coding edit protocols.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2indications reimbursable

1exclusions

1.0version

Enterprise committeegovernance

Reimbursement Criteria for Fecal Calprotectin Testing

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Reimbursement criteria — Fecal calprotectin testing (adults)

Fecal calprotectin testing reimbursement criteria for adults:

Covered when used for the differential diagnosis between non-inflammatory gastrointestinal disease (e.g., IBS) and inflammatory gastrointestinal disease (e.g., IBD).

Covered when used for monitoring gastrointestinal conditions such as inflammatory bowel disease (IBD), including assessment of response to therapy or detection of relapse.

Not covered when used for any other conditions not specified above (fecal calprotectin testing is not reimbursable for other indications).

Documentation and Claims Review

Documentation Required

Documentation and claims review — submit accurate documentation and provide additional records upon request

Providers are responsible for submission of accurate documentation of services performed and are expected to submit claims using valid HIPAA-approved code sets and appropriate industry-standard coding guidelines. Claims are subject to code edit protocols and claim review; upon request, providers are urged to submit any additional documentation.

Submit claims using valid HIPAA-approved code sets and follow industry-standard coding guidelines (e.g., UB, AMA CPT, HCPCS, ICD-10-CM/PCS, NDC).
Claims are subject to code edit protocols, benefit and contract review, medical policies, CPCPs, and coding software logic.
Provide additional documentation upon request to support the claim.

Policy Precedence and Definitions

CPCP and plan document precedence

Policy precedenceIf a conflict exists, the member's plan document governs over the CPCP; if a conflict exists between a CPCP and a provider contract, the provider contract governs.

Examples of plan documentsPlan documents include Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents.

BCBSOK discretionBCBSOK may use reasonable discretion interpreting and applying this policy and has full and final discretionary authority for interpretation and application to the extent provided under applicable plan documents.

Provider responsibilitiesProviders must submit accurate documentation and code claims using valid HIPAA‑approved code sets and industry standard coding guidelines (e.g., UB, AMA CPT, HCPCS, ICD‑10, NDC).

Claim review and documentation submissionClaims are subject to code edit protocols and review against benefit terms, provider contracts, medical policies and coding logic; providers are urged to submit additional documentation upon request.