CurrentBlue Cross Blue Shield - TexasPolicy CPCPLAB065

Human Immunodeficiency Virus (HIV) — Laboratory Testing and Reimbursement

Defines Blue Cross Blue Shield of Texas reimbursement criteria for HIV screening, confirmatory testing, nucleic acid testing, genotyping/phenotyping, and viral load monitoring across applicable products; affects providers submitting lab claims for BCBS Texas members.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyHuman Immunodeficiency Virus (HIV) — Laboratory Testing and Reimbursement

Policy CodePolicy CPCPLAB065

Change TypeRevisions and additions to coverage criteria

Effective DateSep 26, 2025

Next Review Date

Key ActionSubmit accurate documentation on claims and be prepared to provide additional documentation upon request.

SourceLink

POLICY UPDATE CHANGES

Removed frequency restrictions from several test categories and instead referenced Note 1/Note 3 for repeat-interval guidance.

Added coverage statements for screening related to PrEP and for HIV-1/HIV-2 antibody differentiation assay after a positive initial screen.

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

11-65age range specified for routine antigen/antibody screening

>=1reimbursable NAT scenarios listed

multiplegenotyping/phenotyping situations

24procedure codes listed

policy updatesrevision entries

HIV Testing Reimbursement Criteria

Procedure Codes and Repeat-Interval Guidance

Listed HIV-related procedure codesmixed

86689
86701
86702
86703
87389
87390
87391
87534
87535
87536

1–10 of 25

1/3

mixed

No codes listed

Repeat interval - antibody/antigen testing

repeat intervalNot to be repeated more often than once every 90 days (see Note 1)

referenceNote 1: Antibody and antibody/antigen testing should not be repeated more often than once every 90 days.

applies to

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyHuman Immunodeficiency Virus (HIV) — Laboratory Testing and Reimbursement

Policy CodePolicy CPCPLAB065

Change TypeRevisions and additions to coverage criteria

Effective DateSep 26, 2025

Next Review Date

Key ActionSubmit accurate documentation on claims and be prepared to provide additional documentation upon request.

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.

Documentation, Claims, and Provider Responsibilities

Documentation Required

Documentation, coding adherence, and claim review — potential documentation requests and denial risk

Providers must submit accurate documentation and code claims using valid HIPAA-approved code sets and industry-standard coding guidelines; claims are subject to code edit protocols and may be reviewed against plan documents, provider contracts, medical policies, clinical payment and coding policies, and coding software logic. Upon request, providers must furnish additional documentation to support the services billed.

Submit claims using valid code combinations from HIPAA‑approved code sets and follow industry coding guidance (UB, AMA CPT, HCPCS, ICD‑10, NDC, DRG, CMS/NCCI rules).
Claims are subject to code edit protocols and review for benefit coverage, contract terms, medical and clinical payment/coding policies, and coding software logic.
If requested, provide additional documentation to substantiate the claim.

Testing Definitions

Antigen/antibody combination assay

termAntigen/antibody combination assay

definitionA laboratory assay that detects HIV antigen together with HIV antibodies and is used for initial screening for HIV infection.

usageMay be reimbursable for initial screening and for screening related to PrEP or elevated risk (see coverage criteria).

Nucleic acid testing

termNucleic acid testing (NAT)

definitionQualitative or quantitative testing to detect HIV-1 and HIV-2 RNA, used for confirmation after positive/indeterminate screens, suspected recent exposure, and other clinical scenarios.

usageMay be reimbursable for individuals with positive or indeterminate initial screens, suspected recent exposure, and other listed indications (see coverage criteria).

HIV genotyping/phenotyping

termHIV genotyping/phenotyping

definitionLaboratory testing to identify HIV resistance and inform antiretroviral therapy selection and management (includes genotyping and phenotyping assays).

usageMay be reimbursable prior to initiating doravirine, for treatment failure, suboptimal viral load reduction, noncompliance, recent infection, antiretroviral-naïve individuals starting therapy, and pregnant individuals as specified.