CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLABO22

Prenatal Screening for Fetal Aneuploidy

This document describes BCBSOK reimbursement criteria and coding guidance for prenatal screening and related confirmatory testing for fetal aneuploidy; it applies to providers submitting claims to Blue Cross Blue Shield - Oklahoma and may vary by product/plan.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPrenatal Screening for Fetal Aneuploidy

Policy CodePolicy CPCPLABO22

Change TypeNo material changes

Effective DateNov 1, 2023

Next Review Date

Key ActionProviders must submit accurate documentation and use HIPAA-approved codes; claims may be subject to review and require additional documentation on request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1.0policy version

Nov 1, 2023plan effective date

1 newpolicy update history entry

15+codes referenced

multiplescreening not reimbursable conditions

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Reimbursement Criteria and Exclusions

Reimbursement criteria and exclusions

Covered when ALL of the following rules are met:

Confirmatory diagnostic testing via chorionic villus sampling (CVS) or amniocentesis for equivocal or positive prenatal screening results should be offered and may be reimbursable for women wishing to pursue additional testing.

Exclusions (not reimbursable)

Any of the following constitutes a non‑reimbursable screening scenario:
- Screening tests intended to detect fetal aneuploidy performed generally are not reimbursable.
- Parallel or simultaneous testing using multiple screening methodologies for fetal aneuploidy.
- Repeat screening for women with prior negative screening results.
- Screening of multiple gestation pregnancies, except for nuchal translucency and/or subsequent diagnostic testing via CVS or amniocentesis due to high false positive risk.
- Screening related to egg donor pregnancies.
- Screening performed solely for determination of fetal sex.

Operational notes

Not all reimbursement requirements apply to every product; providers should review Plan documents (e.g., Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions) for applicable coverage and the provider contract will govern in case of conflict.
Claims are subject to code‑edit protocols and industry coding guidelines; providers must submit accurate documentation and use HIPAA‑approved code sets. Providers may be requested to submit additional documentation during claim review.
The policy references a list of procedure and laboratory codes relevant to prenatal aneuploidy screening and testing; see coding section for specific CPT/HCPCS codes.

Documentation and Claim Submission

Documentation Required

Documentation, coding, and claim submission requirements

Providers must submit accurate documentation of services performed and file claims using valid HIPAA‑approved code sets. Claims are subject to code edit protocols and may be reviewed; additional documentation may be requested during claim review. When conflicts exist, plan documents and provider contracts govern coverage and BCBSOK may apply discretion in interpretation and application of this policy.

Use valid code combinations from HIPAA‑approved code sets (e.g., CPT, HCPCS, ICD‑10).
Code claims according to industry standard coding guidelines (UB, AMA CPT, HCPCS, CMS NCCI, DRG, etc.).
Claims are subject to code edit protocols and claim review against benefit terms, provider contract language, medical policies, and coding software logic.
Submit additional documentation upon request to support claim adjudication.
When this CPCP conflicts with plan documents or provider contracts, the plan document/provider contract governs.

Plan Documents

Plan documents — definition

Certificates of Health Care BenefitsIncluded as plan documents that govern coverage when they conflict with this CPCP.

Benefit bookletsIncluded as plan documents that govern coverage when they conflict with this CPCP.

Summary Plan DescriptionsIncluded as plan documents that govern coverage when they conflict with this CPCP.

Other coverage documentsAny other coverage documents specified by the plan are considered plan documents and govern coverage in the event of conflict with this CPCP.

Governing authorityIf a conflict arises between this CPCP and any plan document or provider contract, the provider contract/plan documents will govern; BCBSOK may interpret and apply the policy using reasonable discretion.