CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Payment Policy — Human Leukocyte Antigen (HLA) Testing Mandate

Defines Rhode Island state-mandated coverage requirements for HLA testing for BCBSRI members, including one-per-lifetime limit and requirements for National Marrow Donor Program participation and modifier billing.

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 signed informed consent for National Marrow Donor Program participation at time of testing and append modifier 32 when submitting claims for mandated bone marrow screening.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

all BCBSRI memberspopulation covered by mandate

one per lifetimemember testing limit

86813, 86817example CPT codes for HLA typing

modifier 32billing modifier for mandated service

NMDP consentconsent required

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Mandated HLA Testing Coverage

Mandated HLA Testing Criteria

Covered when ALL of the following are met:

ALL of the following

HLA testing for utilization in bone marrow transplantation is covered for all BCBSRI members per Rhode Island law
Testing must include A, B, and DR antigens
Testing must be performed in a facility accredited by the American Association of Blood Banks (or its successors) and licensed under applicable clinical laboratory law
The person tested must complete and sign an informed consent form that authorizes use of the test results for participation in the National Marrow Donor Program
Coverage limits
- The group, hospital, or medical services plan contract may limit each subscriber to one HLA test per lifetime
- Although Rhode Island–mandated benefits generally do not apply to BlueCHiP for Medicare, this service is covered for all BCBSRI members
Billing guidance
- When reporting mandated bone marrow screening, append modifier 32 (mandated service)
- All other uses of HLA testing should be submitted without modifier 32

CPT Codes and Limits

HLA typing CPT codesCPTCovered

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

One-per-lifetime testing limit

Lifetime test limitMembers are limited to one HLA test per lifetime (coverage may be limited to one test per subscriber per lifetime)

Applicable productsBlueCHiP for Medicare and Commercial Products

AuthorityRhode Island General Law (RIGL) 27-20-36 requires coverage and allows a one-per-lifetime limit

Provider Responsibilities and Billing

Prior Authorization

Prior Authorization — Not applicable

Prior authorization is not applicable for HLA testing under this policy. Providers do not need to obtain prior authorization before performing mandated HLA testing.

Billing Rule

Billing and Modifier Guidance

For Rhode Island–mandated bone marrow screening, providers must append modifier 32 (Mandated Service) on claims. Other medically necessary HLA testing (non–Rhode Island mandated uses) should be submitted without modifier 32. Report modifier 32 on claims for the following CPT codes when the test is the mandated service:

86813 — HLA typing; A, B, or C; multiple antigens (append modifier 32 for mandated bone marrow screening)
86817 — HLA typing; DR/DQ, multiple antigens (append modifier 32 for mandated bone marrow screening)

Terms

HLA testing (A, B, DR) — definition

DefinitionHuman leukocyte antigen (HLA) testing (also referred to as histocompatibility locus antigen testing) for A, B, and DR antigens used for utilization in bone marrow transplantation, performed in an AABB‑accredited and licensed facility

Consent requirementPerson tested must complete and sign informed consent authorizing use of results for participation in the National Marrow Donor Program

Use caseSpecifically for matching and utilization in bone marrow transplantation

Modifier 32 — mandated service

Modifier 32 purposeModifier 32 indicates a mandated service and must be appended when reporting Rhode Island–mandated bone marrow screening

When to apply

Documentation Required

Consent / Program Participation

Per Rhode Island statute and program rules, the member must sign a National Marrow Donor Program (NMDP) informed consent form at the time of testing that authorizes use of test results for participation in the NMDP. Providers must obtain and retain the signed consent prior to testing and include it in the medical record. Note: Members are limited to one lifetime test under the state mandate; ensure eligibility and documentation at the time of testing.

Signed NMDP informed consent required at time of testing
Limit: one lifetime test per member under the Rhode Island mandate
Maintain consent and supporting documentation in the patient record for audit/review