CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy | Human Leukocyte Antigen (HLA) Testing Mandate

State-mandated coverage guidelines for HLA testing (A, B, DR antigens) for bone marrow transplantation per Rhode Island law; applies to all BCBSRI members with group/individual plans unless self-funded groups opt out. Specifies one lifetime test limit and billing modifier for mandated tests.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy | Human Leukocyte Antigen (HLA) Testing Mandate

Policy CodePolicy N/A

Change TypeRevised (administrative/billing guidance only)

Effective DateMar 19, 1998

Next Review Date

Key ActionObtain and retain a signed informed consent at time of testing that authorizes results to be used for participation in the National Marrow Donor Program.

SourceLink

POLICY UPDATE CHANGES

Policy last updated 04/02/2020; published in Provider Update June 2020.

1Lifetime tests permitted per member (mandated)

2CPT codes listed for mandated reporting

1998-03-19Effective date of mandate policy

2020-04-02Policy last updated

Coverage Summary

State-mandated coverage of HLA testing (A, B, and DR antigens) for bone marrow transplantation per Rhode Island law. Members are limited to one HLA testing per lifetime (group contracts may impose this limit), and claims for the mandated bone marrow screening must be reported with modifier 32 (Mandated Service). Applicable CPT codes listed for mandated reporting include 86813 and 86817.

Policy effective date: 1998-03-19. Policy last reviewed/updated: 2020-04-02. Published in Provider Update: June 2020.

Key Statistics

Lifetime tests permitted per member1

CPT codes listed for mandated reporting86813, 86817

Effective date1998-03-19

Policy last updated2020-04-02

Coverage Criteria

State-mandated HLA testing coverage

Covered when ALL of the following are met:

ALL of the following

HLA testing purpose: Test is human leukocyte antigen (HLA) testing for A, B, and DR antigens for utilization in bone marrow transplantation
Rhode Island law §27-20-36 requires coverage for A, B, and DR antigens for bone marrow transplantation.
Facility accreditation: Testing is performed in a facility accredited by the American Association of Blood Banks (AABB) or its successors
Facility licensing: Testing is performed in a facility licensed under the Clinical Laboratory Improvement Amendments (CLIA), 42 U.S.C. § 263a
Informed consent: At time of testing, the person being tested completes and signs an informed consent form that authorizes use of results for participation in the National Marrow Donor Program
One test per lifetime: Member is limited to one HLA testing per lifetime (group contract may impose this limit)
Group contracts may limit to one test per lifetime; self-funded groups may opt out.

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Other HLA testing uses

Covered when ALL of the following are met:

ALL of the following

Medical necessity for other uses: HLA testing uses other than the Rhode Island-mandated bone marrow transplantation purpose are covered when medically necessary
All other uses of HLA testing are covered when medically necessary.
Billing for non-mandated tests: Claims for non-mandated HLA testing should be submitted without modifier 32
Modifier 32 is used only for mandated bone marrow screening; non-mandated uses submitted without modifier 32.

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Provider Actions / Billing Requirements

Documentation Required

Informed consent and National Marrow Donor Program participation

Obtain and retain a signed informed consent form at the time of HLA testing that authorizes use of the test results for participation in the National Marrow Donor Program.

Billing Rule

Modifier 32 for mandated service

Submit claims for Rhode Island–mandated HLA bone marrow screening with modifier 32 (Mandated Service). All other HLA testing uses should be submitted without modifier 32.

86813
86817

Documentation Required

Facility accreditation and licensing requirement

Ensure HLA testing is performed in a facility accredited by the American Association of Blood Banks (AABB) or its successor and licensed under CLIA (42 U.S.C. § 263a); billing may depend on these accreditation and licensing requirements being met.

Billing Rule

One test per lifetime

Limit members to one state-mandated HLA test per lifetime as permitted by the group contract.

Background

Rhode Island General Law §27-20-36 requires coverage of human leukocyte antigen (HLA) testing for A, B, and DR antigens for utilization in bone marrow transplantation. The statute specifies that testing must be performed in a facility accredited by the American Association of Blood Banks (AABB) or its successors and in a facility licensed under the Clinical Laboratory Improvement Amendments (CLIA), 42 U.S.C. § 263a.

At the time of testing, the person being tested must complete and sign an informed consent form that authorizes use of the results for participation in the National Marrow Donor Program. Group hospital or medical services plan contracts may limit each subscriber to one of these tests per lifetime. Self-funded groups may choose whether to follow state mandates.

Claims for the Rhode Island-mandated bone marrow screening must be submitted using modifier 32 (Mandated Service); all other uses of HLA testing should be submitted without modifier 32. CPT codes noted for reporting the mandated bone marrow screening include 86813 and 86817.

Modifier used to identify mandated services on claims (Mandated Service).

Revision History

1998-03-19policy_effective

Policy effective date 03/19/1998 establishing state-mandated HLA testing coverage per Rhode Island law.

2013-04-01publication

Published in Provider Update April 2013 (listed in publication history).

2014-12-01publication

Published in Provider Update December 2014 (listed in publication history).

2015-11-01publication

Published in Provider Update November 2015 (listed in publication history).

2016-06-01publication

Published in Provider Update June 2016 (listed in publication history).

2017-06-01publication

Published in Provider Update June 2017 (listed in publication history).

2018-06-01publication

Published in Provider Update June 2018 (listed in publication history).

2019-06-01publication

Published in Provider Update June 2019 (listed in publication history).

2020-04-02policy_updatedLatest

Policy last updated 04/02/2020; published in Provider Update June 2020. Update is non-material and reflects Rhode Island statutory requirements and billing guidance to report mandated HLA bone marrow screening with modifier 32; no clinical policy changes.

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