CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLAB0065

Human Immunodeficiency Virus (HIV)

Defines Blue Cross Blue Shield of Oklahoma reimbursement criteria for HIV laboratory testing (screening, nucleic acid testing, viral load quantification, genotyping/phenotyping) and who may be eligible for reimbursement under plan documents.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyHuman Immunodeficiency Virus (HIV)

Policy CodePolicy CPCPLAB0065

Change TypeMaterial updates to testing indications and frequency limits

Effective DateAug 8, 2025

Next Review Date

Key ActionProviders must submit accurate documentation and may be asked to provide additional documentation upon request; claims are subject to benefit, contract, medical policy and coding review.

SourceLink

POLICY UPDATE CHANGES

Added 'with an antigen/antibody combination assay' to initial screening reimbursement criteria.

Changed repeat screening frequency language to 'no more than one test every 90 days'.

Added nucleic acid testing (qualitative or quantitative) for HIV-1 and HIV-2 with frequency 'no more than one test every month' and specified clinical situations for reimbursement.

Added '(no more than one test every month)' to plasma HIV RNA quantification monitoring.

Added detailed reimbursement rules for genotyping/phenotyping including required situations (e.g., prior to doravirine therapy) and exclusions.

11-65age range for initial screening

≤1/90drepeat screening freq

≤1/moNAAT freq

25codes listed

v1.0policy version

Reimbursable HIV Testing and When It Is Covered

HIV testing reimbursement criteria

Reimbursable services and applicable clinical situations:

ALL of the following

ALL of the following
- Initial screening with an antigen/antibody combination assay may be reimbursable for individuals 11 to 65 years of age.
ALL of the following
- Repeat antigen/antibody screening may be reimbursable for individuals 11 to 65 years of age at a frequency of no more than one test every 90 days.
ALL of the following
- ONE OR MORE of the following qualifies as high risk

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyHuman Immunodeficiency Virus (HIV)

Policy CodePolicy CPCPLAB0065

Change TypeMaterial updates to testing indications and frequency limits

Effective DateAug 8, 2025

Next Review Date

Key ActionProviders must submit accurate documentation and may be asked to provide additional documentation upon request; claims are subject to benefit, contract, medical policy and coding review.

SourceLink

On This Page

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.

ALL of the following

Reimbursable genotyping/phenotyping situations
- Prior to initiating doravirine therapy (genotyping and phenotyping is required).
- For individuals who have failed a course of antiviral therapy.
- For individuals who have suboptimal viral load reduction.
- For individuals who have been noncompliant with therapy.
- To guide treatment decisions in individuals with acute or recent infection (within the last 6 months).
- For antiretroviral-naïve individuals entering treatment.
- For all HIV-infected pregnant individuals in the following situations: before initiation of antiretroviral therapy; for those with detectable HIV RNA loads.
ALL of the following
- For treatment-experienced individuals on failing regimens who are thought to have multidrug resistance, HIV phenotyping may be reimbursable.
ALL of the following
- Routine use of combined genotyping and phenotyping is not reimbursable.
- Drug susceptibility phenotype prediction using genotypic comparison to known genotypic/phenotypic databases is not reimbursable.

ALL of the following

Plasma quantification of HIV-1 RNA or HIV-2 RNA may be reimbursable no more than one test every month.
Reimbursable viral load situations
- For monitoring disease progression in HIV-infected individuals.
- For monitoring response to antiretroviral therapy.
- 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.
ALL of the following
- Because differences in absolute HIV copy number are known to occur using different assays, plasma HIV RNA levels should be measured by the same analytical method; a change in assay method may necessitate re-establishment of a baseline.

Procedure, CPT/HCPCS Codes and Frequency Limits

listed laboratory and screening codesmixed

86689
86701
86702
86703
87389
87390
87391
87534
87535
87536

1–10 of 25

1/3

Repeat antigen/antibody screening frequency limit

Frequency limitRepeat antigen/antibody screening reimbursable no more than one test every 90 days

Age rangeApplies to individuals aged 11 to 65 years

ContextRepeat screening is distinguished from annual high‑risk screening; annual screening may be reimbursable for high‑risk individuals

NAAT frequency limit

Frequency limitNucleic acid testing (qualitative or quantitative) reimbursable no more than one test every month

Reimbursable situationsPositive or indeterminate initial screening; suspected or reported recent exposure

Test scopeApplies to NAAT for HIV‑1 and HIV‑2 (qualitative or quantitative)

Plasma RNA quantification frequency limit

Frequency limitPlasma HIV‑1 or HIV‑2 RNA quantification reimbursable no more than one test every month

Reimbursable indicationsMonitoring disease progression, monitoring response to antiretroviral therapy, infants <18 months born to HIV‑positive mothers, predicting maternal‑fetal transmission

Assay consistencyPlasma HIV RNA should be measured by the same analytical method; changing assay may require re‑establishing baseline

Key Test Definitions

Antigen/antibody combination assay

DefinitionAn antigen/antibody combination assay is the test used for initial HIV screening and may be reimbursable for individuals aged 11 to 65

Use caseRecommended for initial screening of HIV infection in ages 11–65

Relationship to repeat testingRepeat antigen/antibody screening limited to no more than one test every 90 days

Nucleic acid testing (NAAT) for HIV‑1 and HIV‑2

ScopeNucleic acid testing (NAAT) may be qualitative or quantitative for HIV‑1 and HIV‑2

Frequency limitNo more than one NAAT per month when reimbursable

IndicationsReimbursable for positive or indeterminate initial screening and suspected/recent exposure

HIV genotyping and phenotyping — purpose and reimbursement notes

PurposeGenotyping and phenotyping assess HIV drug resistance to guide treatment decisions (e.g., prior to doravirine therapy, treatment failure, suboptimal viral load reduction)

Required usesRequired prior to initiating doravirine therapy; reimbursable for failed therapy, noncompliance, acute/recent infection, antiretroviral‑naïve entering treatment, and specific pregnancy situations

Limitations / exclusionsRoutine combined genotyping and phenotyping is not reimbursable; drug susceptibility phenotype prediction using genotypic comparison to databases is not reimbursable

Documentation, Claims Review, and Frequency/Claim Edits

Documentation Required

Documentation and Claims Review

Providers must submit accurate documentation and may be asked to provide additional records upon request. Claims are subject to review for benefit coverage, provider contract terms, medical and coding policies, and automated code-edit logic. Submit claims using valid HIPAA-approved code sets and follow industry coding guidelines (CPT, HCPCS, ICD-10, NDC, UB, CMS NCCI/CCI, etc.).

Upon request, provide supporting documentation (e.g., medical records, lab reports) to substantiate medical necessity and coding.
Claims may be denied, downcoded, or adjusted if documentation or coding is incomplete or inconsistent with policy or contract terms.

Billing Rule

Frequency Limits and Claim Edits

Adhere to frequency limits and expect claim edits when limits are exceeded. Bill only within the stated timeframes; claims outside these limits may be denied or require additional justification.

HIV antigen/antibody screening: initial testing reimbursable for ages 11–65; repeat antigen/antibody screening — no more than one test every 90 days.
Annual HIV antigen/antibody screening reimbursable for high-risk individuals as listed in policy (e.g., MSM, injection drug users, multiple partners, transactional sex, partners with HIV/STIs, unprotected sex).
HIV nucleic acid testing (qualitative or quantitative): reimbursable when indicated, but limited to no more than one test every month (e.g., positive or indeterminate initial screen, suspected recent exposure).
HIV genotyping/phenotyping: reimbursable in specified clinical situations (e.g., prior to doravirine therapy, treatment failure, suboptimal viral load reduction, noncompliance, acute/recent infection within 6 months, antiretroviral-naïve entering treatment, pregnant individuals before ART initiation or with detectable HIV RNA).
Phenotyping may be reimbursable for treatment-experienced individuals with suspected multidrug resistance.