CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLABO33

Diagnostic Testing of Influenza

This policy defines Blue Cross Blue Shield of Oklahoma's reimbursement stance and criteria for laboratory testing for influenza across BCBSOK products; it affects providers submitting claims for influenza testing services to BCBSOK. Providers should consult plan documents for product-specific applicability.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyDiagnostic Testing of Influenza

Policy CodePolicy CPCPLABO33

Change TypeNon-material wording and reference updates

Effective DateJan 15, 2025

Next Review Date

Key ActionSubmit claims with accurate documentation and valid code combinations; claims are subject to review and plan/contract terms.

SourceLink

POLICY UPDATE CHANGES

Reimbursement Information revised for clarity.

Document updated with literature review.

Codes rearranged to be in numerical order.

1single rapid flu test reimbursable when circulating

0viral culture reimbursable for influenza

0serology testing reimbursable for influenza

0influenza testing for asymptomatic patients

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyDiagnostic Testing of Influenza

Policy CodePolicy CPCPLABO33

Change TypeNon-material wording and reference updates

Effective DateJan 15, 2025

Next Review Date

Key ActionSubmit claims with accurate documentation and valid code combinations; claims are subject to review and plan/contract terms.

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.

Influenza Testing Coverage Criteria

Influenza testing coverage criteria

Reimbursement criteria for influenza diagnostic testing.

Patient exhibits typical influenza signs and symptoms and influenza activity has been documented in the community or geographic area (see Typical Influenza Signs and Symptoms).

See Note 1 for symptom definition.

Allowed tests for symptomatic individuals (when influenza circulating)

One single rapid flu test (either a point-of-contact rapid nucleic acid amplification test [NAAT] or a rapid antigen test) is reimbursable per symptomatic episode.
One single traditional NAAT is reimbursable per symptomatic episode.

Not reimbursable tests

Viral culture testing for influenza is not reimbursable.
Serology testing for influenza is not reimbursable.

Asymptomatic testing: Influenza testing for asymptomatic patients (including rapid antigen, rapid NAAT/RT-PCR, traditional RT-PCR, and viral culture) is not reimbursable.

Applicability may vary by product; providers should review plan documents for eligible coverage and product-specific requirements.

Procedure Codes and Quantities

Procedure codes notemixed

Policy provides a non-exhaustive procedure code list; inclusion does not guarantee coverage.

Number of reimbursable influenza diagnostic tests per symptomatic episode when circulating

Reimbursable tests per symptomatic episode when influenza circulatingOne test: either one single rapid flu test (point-of-care rapid NAAT or rapid antigen) OR one single traditional NAAT — NOT both.

Viral cultureNot reimbursable for influenza.

Serology testingNot reimbursable for influenza.

Asymptomatic testingInfluenza testing for asymptomatic patients (rapid antigen, rapid NAAT/RT-PCR, traditional RT-PCR, viral culture) is not reimbursable.

Documentation and Claim Submission Requirements

Documentation Required

Documentation and claim submission requirements

Providers must submit accurate documentation of services performed and submit claims using valid code combinations from HIPAA‑approved code sets. Claims are subject to claim review and may be adjudicated according to plan documents, provider contract terms, clinical payment and coding policies, code edit protocols, and coding software logic; providers may be asked to provide additional documentation upon request.

Submit claims coded per industry-standard coding guidelines (e.g., CPT, HCPCS, ICD-10-CM/PCS, NDCs, DRG, CMS NCCI edits).
Ensure valid code combinations from HIPAA-approved code sets are used.
Be prepared to supply additional documentation if requested during claim review.

Key Definitions

symptomatic (Typical Influenza Signs and Symptoms)

Fever plus respiratory/systemic symptomFever (100.4°F or higher, or feeling feverish/chills) AND one or more of: cough, sore throat, headache and/or body aches, fatigue, difficulty breathing/shortness of breath, runny or stuffy nose.

Fever definitionTemperature of 100.4°F or higher or feeling feverish/chills.

Respiratory symptomsCough; sore throat; runny or stuffy nose; difficulty breathing or shortness of breath.

Systemic symptomsHeadaches and/or body aches; fatigue.