ModifiedBlue Cross Blue Shield - OklahomaPolicy CPCPLABOS1

Diagnostic Testing of Common Sexually Transmitted Infections

Reimbursement and lab management criteria for diagnostic testing of select STIs (Chlamydia, Gonorrhea, Syphilis, Trichomonas, HSV, HPV) under BCBSOK plans; guidance for providers on when tests may be reimbursable and documentation/coding expectations. Affects providers billing BCBSOK for these tests and members covered under BCBSOK plan documents.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyDiagnostic Testing of Common Sexually Transmitted Infections

Policy CodePolicy CPCPLABOS1

Change TypeReimbursement clarificationadded multitarget PCR reimbursement condition

Effective DateNov 1, 2023

Next Review DateN/A

Key ActionSubmit accurate documentation with claims and provide additional documentation upon request; claims are subject to review and code edits.

SourceLink

POLICY UPDATE CHANGES

Reimbursement information revised for clarity.

Added: When an individual meets the conditions described above for both chlamydia and gonorrhea, multitarget PCR is reimbursable.

References revised; some added, others removed.

New policy = Document updated with literature review.

1.0policy version

2023-11-01plan effective date

2023-04-12approval date

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.

Coverage and Reimbursement Criteria

Reimbursement criteria

Reimbursable and non-reimbursable scenarios for STI testing (covered when the listed conditions are met):

ALL of the following

Once a year assessment for any asymptomatic person in a high-risk category using either a standard or reverse algorithm that includes initial and confirmatory tests (treponemal Ig test AND nontreponemal test)
Once every three months for HIV-positive men or men who have sex with men (MSM)
When a nontreponemal test is used as a test of cure (TOC) for a positive syphilis infection
Diagnosis for any person presenting with signs and/or symptoms of a syphilis infection
As part of newborn screening
As part of follow-up in a victim of sexual assault

ALL of the following

PCR and nucleic acid amplification testing (NAAT) for syphilis is not reimbursable

ALL of the following

Once a year assessment for any asymptomatic person in a high-risk category
Diagnosis for persons presenting with signs and/or symptoms of a chlamydial infection
Diagnosis of suspected lymphogranuloma venereum (LGV)
Test of cure at least three months after initial chlamydial diagnosis
As part of newborn screening
As part of follow-up in a victim of sexual assault

ALL of the following

Once a year assessment for any asymptomatic person in a high-risk category
Diagnosis for persons presenting with signs and/or symptoms of a gonorrheal infection
Test of cure following treatment
Culture testing may be reimbursable for antimicrobial susceptibility if patient does not respond to initial treatment
For asymptomatic individuals not in a high-risk category, screening reimbursable only as part of newborn screening, as follow-up of a sexual assault victim, or for sexually active individuals <18 years (annually)

ALL of the following

NAAT/PCR reimbursable for symptomatic individuals
NAAT/PCR reimbursable for asymptomatic individuals in high-risk groups or high-prevalence settings (e.g., STI clinics) or individuals who exchange sex for payment
Exclusion: Rapid enzyme immunoassay for Trichomonas is not reimbursable

ALL of the following

NAAT for HSV-1 or HSV-2 reimbursable for individuals with active genital ulcers or mucocutaneous lesions
Exclusions: Nonspecific immunoassay testing for HSV-1 and screening of asymptomatic individuals for HSV-1/HSV-2 are not reimbursable
Note: Type-specific serology for HSV-2 (gG2) may be reimbursable in select clinical scenarios such as recurrent or atypical genital symptoms with negative PCR/culture, clinical diagnosis with negative PCR/culture, or when patient's partner has genital herpes

ALL of the following

Testing for high-risk HPV (IHC or NAAT) may be reimbursable in the diagnosis and/or assessment of cancer or cancer therapy
Exclusions: HPV testing is not reimbursable for anogenital wart diagnosis, general asymptomatic STI screening panels for HR types, low-risk type screening, or NAAT to determine HPV status in the general population

ALL of the following

Baseline and periodic HIV antibody testing and renal function testing (serum creatinine and estimated creatinine clearance) when initiating and during PrEP
HBV and HCV screening and pregnancy testing as part of baseline evaluation
NAAT screening for gonorrhea and chlamydia by anatomic site per CDC guidance at recommended intervals (e.g., every 3 months for MSM and individuals with child-bearing potential; other specified frequencies per policy)
Exclusion: Using nucleic acid testing to quantify organisms (C. trachomatis, N. gonorrhoeae, HSV-1, HSV-2, T. pallidum, HPV) is not reimbursable

ALL of the following

For asymptomatic individuals not in a high-risk category, screening for chlamydia or gonorrhea may be reimbursable only for newborn screening, follow-up of sexual assault, or sexually active individuals <18 years (annually)

Reimbursable testing criteria (partial)

Policy update specifies an added reimbursable condition:

ALL of the following

Condition: When an individual meets the conditions described above for both chlamydia and gonorrhea
Action: Multitarget PCR testing (targets limited to C. trachomatis and N. gonorrhoeae) may be reimbursable
Note: This condition was added in the 8/15/2023 policy update; full conditions text appears in the coverage criteria for chlamydia and gonorrhea

ALL of the following

Multitarget PCR reimbursement applies only when the individual meets the policy-specified conditions for both chlamydia and gonorrhea (see chlamydia and gonorrhea NAAT criteria)

Procedure Codes and Coding Expectations

listed procedure codesCPT

82565
82575
84702
84703
86592
86593
86631
86632
86694
86695

1–10 of 24

1/3

Referenced but codes not listed in this excerptmixed

No codes listed

Reimbursement condition threshold — When conditions for both chlamydia and gonorrhea are met

ThresholdWhen an individual meets the conditions described above for both chlamydia and gonorrhea

ContextThis threshold was added in the 8/15/2023 policy update clarifying reimbursement for multitarget PCR when both CT and NG criteria are met

ActionMultitarget PCR testing is reimbursable only when both chlamydia and gonorrhea conditions are satisfied

Provider Responsibilities and Billing Guidance

Documentation Required

Documentation and claim review: submit accurate documentation and provide additional records on request

Providers are responsible for submission of accurate documentation of services performed and must submit claims using valid HIPAA-approved code sets. Claims are subject to claim review and code edit protocols; upon request, providers are urged to submit additional documentation to support billed services.

Submit claims using HIPAA-approved code sets (AMA CPT, HCPCS, ICD-10, NDC, DRG, CMS NCCI).
Claims are subject to code edit protocols, benefit and contract review, medical policies, payment and coding policies, and coding software logic.
Provide additional documentation upon request to support claims.

Billing Rule

Reimbursement for multitarget PCR when criteria for both chlamydia and gonorrhea are met

Scope and Terminology

Coding expectations — Providers expected to submit claims using HIPAA-approved code sets and follow industry standards

ExpectationProviders must submit claims using valid code combinations from HIPAA‑approved code sets (e.g., AMA CPT, HCPCS, ICD‑10, NDC, DRG)

GuidanceClaims should be coded per industry standard coding guidelines including UB Editor, AMA CPT, CMS NCCI policy manual and CCI table edits

DocumentationProviders are responsible for submission of accurate documentation and may be asked to provide additional documentation upon request; claims are subject to review and code edit protocols

Scope of tests — Policy scope limited to testing for listed pathogens

Covered pathogensPolicy limited to testing for Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum, Trichomonas vaginalis, HSV, and HPV