CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Human Leukocyte Antigen (HLA) Testing Mandate

Documents Rhode Island state-mandated coverage guidelines for HLA testing (A, B, DR antigens) for Blue Cross & Blue Shield of Rhode Island members, including requirements for National Marrow Donor Program participation and billing modifier guidance. Applies to Medicare Advantage and Commercial products administered by BCBSRI; self-funded groups may opt out.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyHuman Leukocyte Antigen (HLA) Testing Mandate

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMar 19, 1998

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1lifetime test limitation per member (may be limited by contract)

86813,86817CPT codes specifically cited for HLA testing

03-19-1998mandate effective date

10-20-2021policy last updated

State-mandated and Medical Necessity Criteria

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State-mandated HLA testing for bone marrow transplantation

Coverage required by Rhode Island law for HLA testing when used for utilization in bone marrow transplantation; additional rules apply:

ALL of the following

Testing is for A, B, and DR antigens (histocompatibility locus antigen testing) for utilization in bone marrow transplantation
Testing must be performed in a facility accredited by the American Association of Blood Banks (AABB) or its successors
Testing facility must be licensed under the Clinical Laboratory Improvement Amendments (CLIA), 42 U.S.C. § 263a
At time of testing, a signed informed consent form must be completed that authorizes results to be used for participation in the National Marrow Donor Program
See provider documentation requirement: obtain and retain signed informed consent authorizing use for the National Marrow Donor Program (brief provider action).
Group contracts may limit each subscriber to one of these tests per lifetimeone test per lifetime
Benefit booklets/contracts determine if the lifetime limit is applied

Coverage for other uses of HLA testing

Non-mandated uses:

ANY of the following

All other uses of HLA testing are covered when medically necessary

Codes and Billing Guidance

HLA testing CPT codes citedCPTCovered

86813	HLA typing; A, B, or C, multiple antigens
86817	HLA typing; DR/DQ, multiple antigens

Mandated-service billing guidanceModifier

32	Modifier 32 — Mandated Services (to be appended to claims for bone marrow screening/testing mandated by state law)

Billing Rule

Use modifier 32 for mandated tests

Append modifier 32 to claims for bone marrow screening/testing that are mandated by Rhode Island law; other HLA testing uses should be submitted without modifier 32.

86813
86817
Modifier 32

Documentation, Prior Auth, and Contract Risk

Documentation Required

Signed informed consent required

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

Applicable CPT codes: 86813, 86817

Prior Authorization

Prior authorization not applicable

Prior authorization is not applicable for the Rhode Island–mandated HLA testing per this policy; however, benefits may vary by contract and self-funded groups may not follow the mandate.

Denial Risk

Coverage dependent on contract

Verify member-specific benefits before testing: self-funded group plans may opt out of state mandates and benefit booklets or subscriber agreements may limit coverage (e.g., one test per lifetime), which can result in denied claims.

Threshold: one test per lifetime may apply if limited by group contract

Clinical and Regulatory Background

Rhode Island General Law §27-20-36 mandates coverage of human leukocyte antigen (HLA) testing (also called histocompatibility locus antigen testing) for the A, B, and DR antigens when used 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 licensed under the Clinical Laboratory Improvement Amendments (CLIA), 42 U.S.C. § 263a. (RIGL text: §27-20-36.)

A signed informed consent form must be completed at the time of testing that authorizes use of the test results for participation in the National Marrow Donor Program; providers must obtain and retain this consent when performing mandated testing.

For claims reporting of Rhode Island–mandated bone marrow screening/testing, append modifier 32 (Mandated Services). CPT codes cited for HLA testing in this policy include 86813 (HLA typing; A, B, or C, multiple antigens) and 86817 (HLA typing; DR/DQ, multiple antigens). All other uses of HLA testing that are not state-mandated remain subject to usual medical necessity rules and should be billed without modifier 32.

Group benefit booklets, Evidence of Coverage, or Subscriber Agreements determine specific laboratory benefits; the statute allows a group plan to limit each subscriber to one test per lifetime, and self-funded groups may choose not to follow the state mandate. Verify member-specific benefits to confirm applicability and avoid denied claims.

Scope and status

Scope summaryDocuments Rhode Island state-mandated coverage guidelines for HLA testing (A, B, DR antigens) for Blue Cross & Blue Shield of Rhode Island members, including requirements for National Marrow Donor Program participation and billing modifier guidance. Applies to Medicare Advantage and Commercial products administered by BCBSRI; self-funded groups may opt out.

Applies toMedicare Advantage and Commercial products administered by BCBSRI; self-funded groups may opt out.

StatusCURRENT

Defined Terms

Definitions

National Marrow Donor ProgramA program facilitating bone marrow donor registry and matching; participation requires signed informed consent authorizing use of HLA test results.

Modifier 32CPT modifier indicating a service was required by a public authority (mandated services); to be appended to claims for bone marrow screening/testing mandated by Rhode Island law.

HLA testing (A, B, DR) requirementTesting must be performed in an AABB-accredited and CLIA-licensed laboratory and a signed informed consent must authorize use of results for the National Marrow Donor Program.