CurrentBlue Cross Blue Shield - TexasPolicy CPCPLABO6S

Human Immunodeficiency Virus (HIV) — Laboratory Testing Reimbursement

Reimbursement criteria and coding guidance for HIV screening, confirmatory, nucleic acid, genotyping/phenotyping, and viral load testing for Blue Cross Blue Shield of Texas members; applies to providers submitting claims under BCBSTX plans.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyHuman Immunodeficiency Virus (HIV) — Laboratory Testing Reimbursement

Policy CodePolicy CPCPLABO6S

Change TypeCoverage additions and frequency guidance revisions

Effective DateSep 26, 2025

Next Review Date

Key ActionSubmit accurate coding and supporting documentation upon request; claims are subject to contract, benefit, and coding policy review and edits.

SourceLink

POLICY UPDATE CHANGES

Added reimbursement for screening individuals who will begin or are receiving PrEP and those with elevated risk factors, and added reimbursement for HIV-1/HIV-2 antibody differentiation assay following a positive initial screen.

Removed frequency limits phrasing from repeat antibody/antigen and nucleic acid testing and replaced them with references to Note 1 and Note 3.

Added explicit statement that HIV antigen testing independent of antigen/antibody testing is not reimbursable.

Added list of specific CPT/HCPCS codes referenced for HIV testing.

11-65age range for routine Ag/Ab screening

Note-basedtesting frequency

Codes listedprocedure codes referenced

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyHuman Immunodeficiency Virus (HIV) — Laboratory Testing Reimbursement

Policy CodePolicy CPCPLABO6S

Change TypeCoverage additions and frequency guidance revisions

Effective DateSep 26, 2025

Next Review Date

Key ActionSubmit accurate coding and supporting documentation upon request; claims are subject to contract, benefit, and coding policy review and edits.

SourceLink

On This Page

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.

Reimbursable Services and Clinical Conditions

Reimbursable services and conditions

Reimbursable HIV laboratory services when clinical or situational criteria are met:

Screening (antigen/antibody or rapid antibody)
- Initial screening with an antigen/antibody combination assay for individuals 11 to 65 years of age may be reimbursable.
- Repeat antigen/antibody screening for individuals 11 to 65 years of age may be reimbursable (see Note 1 for repeat interval).
- Screening with an antigen/antibody combination assay or with a rapid antibody test may be reimbursable for individuals receiving pre‑exposure prophylaxis (PrEP) or for individuals with elevated risk factors for HIV infection (see Note 2).
Confirmatory antibody differentiation
- HIV‑1/HIV‑2 antibody differentiation assay may be reimbursable for individuals whose initial screening was positive (see Note 1).
Nucleic acid testing (qualitative or quantitative)
- Nucleic acid testing for HIV‑1 and HIV‑2 may be reimbursable for individuals with a positive initial screening result.
- Nucleic acid testing may be reimbursable for individuals with an indeterminate initial screening result.
- Nucleic acid testing may be reimbursable for individuals with suspected or reported recent exposure.
Genotyping / Phenotyping
- HIV genotyping or phenotyping may be reimbursable for treatment‑experienced individuals on failing regimens who are suspected to have multidrug resistance (phenotyping may be reimbursable).
- Genotyping or phenotyping may be reimbursable for individuals who have failed a course of antiviral therapy or who have suboptimal viral load reduction.
- Genotyping or phenotyping may be reimbursable for individuals who have been noncompliant with therapy, for antiretroviral‑naive individuals entering treatment, and to guide treatment decisions in individuals with acute or recent infection (within the last 6 months).
- Genotyping or phenotyping may be reimbursable for HIV‑infected pregnant individuals in specified situations, including those with detectable HIV RNA loads and before initiation of antiretroviral therapy.
Plasma HIV RNA quantification (viral load)
- Plasma quantification of HIV‑1 RNA or HIV‑2 RNA may be reimbursable for monitoring disease progression in HIV‑infected individuals.
- Plasma quantification may be reimbursable for monitoring response to antiretroviral therapy.
- Plasma quantification may be reimbursable for infants younger than 18 months born to HIV‑positive mothers (antibody tests may be confounded by maternal antibodies).
- Plasma quantification may be reimbursable for predicting maternal‑fetal transmission of HIV‑1 or HIV‑2.

HIV antigen testing performed independent of an antigen/antibody combination assay is not reimbursable.

Routine combined use of genotyping and phenotyping is not reimbursable. Drug susceptibility phenotype prediction using genotypic comparison to known databases is not reimbursable.

Procedure Codes and Frequency Guidance

Referenced HIV test procedure codesmixed

86689
86701
86702
86703
87389
87390
87391
87534
87535
87536

1–10 of 14

1/2

Covered CPT CodesCPT

No codes listed

Antibody/antigen repeat frequency

Repeat intervalAntibody and antigen/antibody testing should not be repeated more often than once every 90 days (see Note 1)

ScopeApplies to antibody and antigen/antibody combination screening and repeat screening events

Exceptions referencedSee Note 1 for details and exceptions related to testing intervals

Nucleic acid testing frequency

Repeat intervalNucleic acid testing (qualitative or quantitative) should not be repeated more often than once every month (see Note 1 and Note 3)

When reimbursableNAAT may be reimbursable for suspected recent exposure, positive or indeterminate initial screening, and monitoring as listed in policy

Documentation, Claims, and Contract Interpretation

Documentation Required

Documentation and claim submission — submit accurate coding and supporting documentation upon request

Providers must submit accurate coding using HIPAA-approved code sets and provide supporting documentation upon request. Claims are subject to code edit protocols and review for contract, benefit, medical policy, and coding policy compliance; additional documentation should be provided when requested.

Submit claims coded per industry standard code sets (e.g., CPT, HCPCS, ICD-10) and guidelines.
Provide additional clinical or billing documentation upon request to support medical necessity and coding.
Expect claims to be reviewed against contract terms, benefit coverage, clinical payment and coding policies, and code-edit logic.

Billing Rule

Terms and Notes

pre-exposure prophylaxis (PrEP)

DefinitionPre-exposure prophylaxis (PrEP): preventive treatment given to individuals to reduce the risk of acquiring HIV; individuals receiving PrEP are listed as a group for whom screening may be reimbursable.

Policy contextScreening for HIV infection with an antigen/antibody combination assay or rapid antibody test may be reimbursable for individuals receiving PrEP (see policy list).

Age range noteReimbursement for initial screening with Ag/Ab assay referenced for individuals 11 to 65 years of age (see policy).

Ag/Ab combination assay

DefinitionAntigen/antibody (Ag/Ab) combination assay: a screening test that detects both HIV antigen and antibodies to HIV and is referenced as the initial screening method in policy.

Use in policy