CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLABOO6S

Human Immunodeficiency Virus (HIV) - Laboratory Testing and Reimbursement

This policy governs reimbursement criteria for HIV-related laboratory tests (screening, RNA quantification, genotyping/phenotyping) for Blue Cross Blue Shield of Oklahoma members; providers should confirm plan-specific coverage.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyHuman Immunodeficiency Virus (HIV) - Laboratory Testing and Reimbursement

Policy CodePolicy CPCPLABOO6S

Change TypeReferences/literature updatedno material coverage change

Effective DateJan 15, 2025

Next Review DateN/A

Key ActionSubmit accurate documentation with claims and provide additional documentation upon request for reimbursement review.

SourceLink

POLICY UPDATE CHANGES

Document updated with literature review; reimbursement information unchanged; references revised.

Reimbursement information revised for clarity and items regarding genotyping and phenotyping were added in a prior update.

11-65age range for recommended initial and repeat HIV screening

≥90 daysminimum interval for repeat screening

Annualscreening frequency for high-risk individuals

Not reimbursable

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HIV Testing and Monitoring Criteria

HIV testing and monitoring criteria

Reimbursement may be available under specified clinical scenarios; providers should confirm member plan eligibility.

ALL of the following

ALL of the following
- For individuals 11 to 65 years of age, initial screening for HIV infection may be reimbursable.
ALL of the following
- For individuals 11 to 65 years of age, repeat screening for HIV infection may be reimbursable no less than 90 days after initial screening.

ALL of the following

Annual screening may be reimbursable for individuals considered at high risk, including: men who have sex with men (MSM); injection drug users; individuals who have sex for drugs or money; individuals with multiple sex partners; individuals who have sex with someone who is HIV-positive or has other sexually transmitted infections; and individuals having sex without the use of a condom.

ALL of the following

ANY of the following
- Prior to initiating doravirine therapy (genotyping and phenotyping is required).
- Individuals who have failed a course of antiviral therapy.
- Individuals with suboptimal viral load reduction.
- Individuals who have been noncompliant with therapy.
- Antiretroviral-naive individuals entering treatment.
- To guide treatment decisions in individuals with acute or recent infection (within the last 6 months).

ALL of the following

ANY of the following
- For monitoring response to antiretroviral therapy.
- For monitoring disease progression in HIV-infected individuals.
- For infants younger than 18 months born to HIV-positive mothers (antibody tests may be confounded by maternal antibodies).
- For predicting maternal-fetal transmission of HIV-1 or HIV-2.
- When the risk of HIV infection is significant and initiation of therapy is anticipated, a baseline HIV quantification may be reimbursable, including: in an at-risk individual with persistence of borderline or equivocal serologic reactivity; or in an at-risk individual with signs and symptoms of acute retroviral syndrome (fever, malaise, lymphadenopathy, rash).

ALL of the following

Not all requirements apply to each product; providers should review member plan documents for eligibility. If a conflict arises between this policy and a member's plan document, the plan document governs. BCBSOK may exercise discretion in application.

Procedure Codes and Billing

Listed procedure codes (not all-inclusive)mixed

87539
87806
87900
87901
87903
87904
87906
0219U
60432
60433

1–10 of 13

1/2

Listed procedure codes (not all-inclusive) - duplicate group placeholdermixed

No codes listed

Documentation, Claims and Provider Responsibilities

Documentation Required

Documentation, coding and claim-review obligations

Providers must submit accurate documentation and correctly coded claims and be prepared to provide additional records upon request. Claims are subject to code edit protocols and review against benefit coverage, provider contract language, medical policies, clinical payment and coding policies, and coding software logic; plan documents govern in the event of a conflict.

Submit claims using valid code combinations from HIPAA-approved code sets and code appropriately per industry standard coding guidelines (e.g., CPT, HCPCS, ICD-10-CM/PCS, NDC, DRG).
Claims are subject to code edit protocols (e.g., CCI table edits) and review; BCBSOK may request additional documentation — providers should respond to requests.
If a conflict exists between this policy and a member's plan document or provider contract, the plan document or contract governs.

Plan Documents and Definitions

Plan documents (definitions and applicability)

DefinitionPlan documents include Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents used by Blue Cross and Blue Shield of Oklahoma.

Governing hierarchyIf a conflict arises between this Clinical Payment and Coding Policy and any plan document under which a member is entitled to Covered Services, the plan document will govern.

Provider contract precedenceIf a conflict arises between this CPCP and any provider contract, the provider contract will govern with respect to participating providers and plans.

Discretionary authorityBCBSOK may use reasonable discretion in interpreting and applying this policy and has full and final discretionary authority to the extent provided under applicable plan documents.

Provider responsibilitiesProviders are responsible for submitting accurate documentation and coding and may be asked to provide additional documentation upon request; claims are subject to coding edits and review against plan and contract terms.