CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLABO14

Prenatal Screening

Defines BCBSOK reimbursement criteria for routine prenatal screening laboratory tests and related lab management rules that apply to covered pregnant members; affects providers submitting claims to Blue Cross Blue Shield of Oklahoma.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPrenatal Screening

Policy CodePolicy CPCPLABO14

Change TypeNo material change

Effective DateNov 1, 2022

Next Review Date

Key ActionProviders must submit accurate documentation and use valid HIPAA-approved code sets; claims are subject to review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1new policy (Policy created)

~70listed codes

multipleroutine screenings

24-28wGDM window

Routine Prenatal Screening Coverage Criteria

Routine prenatal screening coverage and conditions

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ALL of the following

HIV screening - reimbursable for all pregnant women
Chlamydia trachomatis screening - reimbursable for all pregnant women
Neisseria gonorrhea screening - reimbursable for all pregnant women
Syphilis screening - reimbursable for all pregnant women
Hepatitis B screening - reimbursable for all pregnant women
Screening for bacteriuria (urinalysis/urine culture) - reimbursable
Fetal aneuploidy screening - reimbursable in accordance with CPCPLABO2Z
Type 2 diabetes screening at the first prenatal visit - reimbursable
Gestational diabetes screening during gestational weeks 24-28 (or at first prenatal visit if risk factors present) - reimbursable
Blood type, Rh(D) determination and antibody testing at first prenatal visit - reimbursable
Repeat Rh(D) antibody testing at 24-28 weeks for unsensitized Rh(D)-negative women unless biological father known Rh(D)-negative - reimbursable
Group B Streptococcus (GBS) screening once, recommended at 36-37 weeks - reimbursable
Anemia screening (CBC or Hgb/Hct with MCV) - meets coverage criteria
Rubella and varicella immunity testing - reimbursable
TB screening for pregnant women at high risk - reimbursable

High-risk and repeat testing criteria

Reimbursable high-risk and repeat testing when criteria below are met.

ANY of the following

Third trimester repeat STI/HIV: Third trimester re-screening of Chlamydia trachomatis, Neisseria gonorrhea, syphilis, and/or HIV infections is reimbursable if ANY one high-risk criterion is present: sexually active young individuals under 25 years; new or multiple sexual partners; past history of sexually transmitted diseases; current sex work; past or current injection drug use.
Rapid HIV testing in labor: Rapid HIV testing for pregnant women who present in active labor with an undocumented HIV status may be reimbursable.
Fetal Fibronectin (FFN) assay - reimbursable use
- Intact membranes
- Singleton or twin gestation
- Cervical dilation < 3 cm
- Patient experiencing symptoms suggestive of preterm labor between 24 and <35 weeks' gestation
FFN assay - not reimbursable: All other applications of the FFN assay are not reimbursable, including routine monitoring in asymptomatic women, monitoring asymptomatic high‑risk women (including multiple gestations, history of preterm birth, uterine malformation, cervical incompetence, or history of ≥2 spontaneous second trimester abortions), use in triplet or higher‑order gestations, or to identify term women likely to deliver within 24–48 hours.
Serial salivary estriol: Serial monitoring of salivary estriol levels for risk assessment of preterm labor or delivery is not reimbursable.

Thyroid and RHD testing

Testing that may be reimbursable when specific clinical conditions or histories are present.

ANY of the following

Thyroid dysfunction testing: Testing for thyroid dysfunction may be reimbursable if the pregnant woman has any of the following: personal history of thyroid disease; symptoms of thyroid disease; or personal history of medical conditions associated with thyroid disease (for example, diabetes mellitus, goiter, iodine deficiency).
Fetal RHD genotyping using maternal plasma may be reimbursable in RHD‑negative pregnant women.

Coding and Test Windows

Examples from listed lab codesCPT

80081
80055
81001
G0306

Gestational diabetes screening window

Gestational diabetes screening windowScreening during gestational weeks 24-28 (or at the first prenatal visit if risk factors are present)

Type 2 diabetes screeningScreening at the first prenatal visit

Rh(D) antibody repeat testing timingRepeat antibody testing for unsensitized Rh(D)-negative women at 24-28 weeks unless father known Rh-negative

Group B Streptococcus timingScreening once, recommended during weeks 36-37

Claims Submission and Review Requirements

Documentation Required

Submit accurate documentation and use HIPAA‑approved code sets; claims subject to review

Providers are responsible for submitting accurate documentation of services performed and must bill using valid code combinations from HIPAA‑approved code sets. Claims are subject to claim review, including benefit coverage terms, provider contract language, medical policies, clinical payment and coding policies, and code‑edit protocols; upon request, providers should submit additional supporting documentation.

Submit claims using valid HIPAA‑approved code sets (CPT, HCPCS, ICD‑10, NDC, DRG guidelines, etc.).
Code claims appropriately per industry coding guidelines (e.g., UB Editor, AMA CPT, CMS NCCI/CCI edits).
Be prepared to provide additional documentation upon request for claim review or adjudication.

Policy Description and Definitions

Lab management reimbursement criteria — description

DefinitionLab management reimbursement criteria established by BCBSOK governing when prenatal laboratory tests may be reimbursable; not all requirements apply to each product—review plan documents for coverage details.

Provider responsibilityProviders are urged to review plan documents for eligible coverage for services rendered and to follow applicable product rules.

ScopeApplies to routine prenatal screening tests and select additional prenatal laboratory tests listed in the policy (coverage with criteria).

Claim reviewClaims are subject to review and must conform to contract and plan document provisions (see related policy provisions).