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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyBlue KC hepatitis testing Coverage Update | OpenPa…
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    CurrentBlue KCPolicy POL-PP-285

    Payment Integrity Compliance — Hepatitis Testing

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    Defines Blue KC's payment integrity and reimbursement rules for hepatitis A, B, C, and D diagnostic testing across impacted provider types and lines of business. Applies to claims adjudication and reimbursement decisions for covered members based on benefit coverage and clinical criteria.

    Policy Summary
    PayerBlue KC
    PolicyPayment Integrity Compliance — Hepatitis Testing
    Policy CodePolicy POL-PP-285
    Change TypeNo material changes
    Effective DateJul 1, 2025
    Next Review DateJul 1, 2026
    Key ActionConfirm member eligibility, benefit limits, date of service, and provider agreement to verify coverage prior to providing hepatitis testing.
    SourceLink

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    once/lifetimeHCV antibody testing reimbursable for adults ≥18
    once/lifetimeHBV triple panel reimbursable for adults ≥18
    q3 monthsHCV antibody testing for ongoing risk
    multipleHCV quantitative viral load timing
    not reimb.HAV/HDV quantitative NAAT

    Hepatitis Testing Coverage Criteria

    Hepatitis B coverage

    Covered when the following criteria are met:

    Adults (≥18 years): Hepatitis B triple panel (HBsAg, anti-HBs, anti-HBc) — one-time lifetime testing may be reimbursable.

    Annual screening for asymptomatic, non-pregnant individuals when any of the following high-risk situations is present:

    • Born in or recently traveled to geographic regions with HBV prevalence ≥2%.
    • U.S.-born individuals not vaccinated as infants whose parents were born in regions with HBV prevalence ≥8%.
    • History of incarceration.
    • HIV infection.
    • History of sexually transmitted infections or multiple sex partners.
    • Men who have sex with men (MSM).
    • Household contacts, needle-sharing contacts, or sex partners of HBV-infected individuals.
    • Injection-drug use.
    • Active HCV infection or history of HCV infection.
    • Elevated liver enzymes.
    • Long-term hemodialysis treatment.
    • Diabetes.
    • Healthcare and public safety workers exposed to blood or body fluids.
    • Receiving immunosuppressant therapy.
    For infants born to an HBsAg-positive individual: annual HBsAg and anti-HBs testing may be reimbursable.
    Anti-HBs testing for confirmation of seroconversion after hepatitis B vaccination may be reimbursable.
    For individuals who test positive for HBV by initial antibody screening and who will undergo immunosuppressive drug therapy: HBV DNA testing may be reimbursable.

    Hepatitis C coverage

    Covered when the following criteria and timing are met:

    Adults (≥18 years): HCV antibody testing — one-time lifetime testing may be reimbursable.

    One-time post-exposure or condition-based antibody testing may be reimbursable for individuals with any of the following:

    • Current or past illicit intranasal or injectable drug use.
    • Receipt of clotting factor concentrates produced before 1987.
    • History of hemodialysis.
    • Evidence of liver disease (clinical presentation, persistently abnormal ALT, or abnormal liver function studies).

    Hepatitis A coverage

    Covered when clinically indicated for acute presentation:

    Individuals with signs and symptoms of acute viral hepatitis who have tested negative for HBV and HCV: IgM anti-HAV testing or qualitative HAV RNA testing may be reimbursable.
    Quantitative nucleic acid testing for HAV viral load is not reimbursable.

    Hepatitis D coverage

    Covered when HBV infection is present:

    Individuals who have tested positive for HBV: anti-HDV (hepatitis D antibody) or qualitative HDV RNA testing may be reimbursable.
    Quantitative nucleic acid testing for HDV viral load is not reimbursable.

    Billing Codes and Frequency Rules

    Listed hepatitis-related CPT/G codes and descriptionsCPT
    86692Antibody; hepatitis, delta agent
    86704Hepatitis B core antibody (HBcAb); total
    86705Hepatitis B core antibody (HBcAb); IgM antibody
    86706Hepatitis B surface antibody (HBsAb)
    86709Hepatitis A antibody (HAAb), IgM antibody
    86803Hepatitis C antibody
    86804Hepatitis C antibody: confirmatory test (e.g., immunoblot)
    87340Infectious agent antigen detection by immunoassay technique; hepatitis B surface antigen (HBsAg)
    87341Infectious agent antigen detection by immunoassay technique; hepatitis B surface antigen (HBsAg) neutralization
    87516Infectious agent detection by nucleic acid (DNA or RNA); hepatitis B virus, amplified probe technique
    1–10 of 19
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    inv-06: HCV antibody frequency (ongoing risk)
    FrequencyAntibody testing for HCV once every 3 months while ongoing risk factors persist (e.g., current injection drug use with sharing, ongoing hemodialysis, high-risk sexual behavior)
    Applicable populationIndividuals with ongoing risk factors for HCV (current injection drug use with sharing, receiving ongoing hemodialysis, engaging in high-risk sexual behavior)
    Reimbursement stanceMay be reimbursable while risk factors persist
    Related actionsRepeat testing every 3 months for duration of ongoing exposure risk
    inv-07: One-time lifetime screening — HBV and HCV antibody testing
    One-time lifetime screeningAntibody testing for Hepatitis B and Hepatitis C once per lifetime for individuals aged ≥18 may be reimbursable

    Provider Responsibilities and Coverage Verification

    Prior Authorization

    Coverage verification — confirm member eligibility, benefit limits, date of service, and provider agreement prior to testing

    Confirm member eligibility, benefits, and provider participation before ordering or performing tests. Coverage and payment are subject to the member's benefit plan at the date of service and the provider's agreement with Blue KC. Verifying these elements in advance reduces the risk of claim denials and unexpected member liability.

    • Confirm member eligibility and active coverage for the date of service
    • Verify plan benefit limits, frequency restrictions, and any applicable cost-sharing (copay, coinsurance, deductible)
    • Check medical necessity and coverage criteria for the requested service under the member's specific plan
    • Determine whether prior authorization or precertification is required and obtain authorization before service when required
    • Verify provider participation/network status and that the rendering provider is contracted and credentialed with Blue KC for the service
    • Document verification steps (date/time, representative, confirmation number) in the medical record and claims documentation

    Definitions

    inv-09: Infectious hepatitis — definition, transmission routes, and scope
    DefinitionInfectious hepatitis: inflammation of the liver caused by hepatitis viruses (A, B, C, D), which can lead to acute and, for some viruses, chronic liver disease including cirrhosis and hepatocellular carcinoma
    Hepatitis C transmissionBloodborne transmission (sharing needles or injection equipment; inadequate infection control in healthcare settings)
    Hepatitis B transmissionPercutaneous, mucosal, or nonintact skin exposure to infectious blood, semen, and other body fluids; also perinatal (birth), sexual contact, needle sticks, organ transplantation, dialysis, and sharing personal items
    Hepatitis A transmissionPrimarily fecal–oral route through close person-to-person contact, sexual contact, or ingestion of contaminated food or water; bloodborne transmission uncommon
    inv-10: HBV triple panel — components
    Policy Summary
    PayerBlue KC
    PolicyPayment Integrity Compliance — Hepatitis Testing
    Policy CodePolicy POL-PP-285
    Change TypeNo material changes
    Effective DateJul 1, 2025
    Next Review DateJul 1, 2026
    Key ActionConfirm member eligibility, benefit limits, date of service, and provider agreement to verify coverage prior to providing hepatitis testing.
    SourceLink
    On This Page
    Hepatitis Testing Coverage CriteriaBilling Codes and Frequency RulesProvider Responsibilities and Coverage VerificationDefinitions
    HIV infection.
  1. Organ transplant before July 1992.
  2. Blood transfusion or blood component before July 1992.
  3. Notified that they received blood from a donor who later tested positive for HCV.
  4. History of incarceration.
  5. Tattoo received in an unregulated setting.
  6. Healthcare, emergency medical, or public safety workers after needle sticks, sharps, or mucosal exposures to HCV-positive blood.
  7. Children born to HCV-positive individuals.
  8. Current sexual partners of HCV-infected persons.
    9. Antibody testing every 3 months while ongoing risk factors persist (e.g., current injection drug use with sharing, ongoing hemodialysis, high-risk sexual behavior).

    Qualitative nucleic acid (NAAT) testing may be reimbursable in the following situations:

    • As follow-up for individuals who test positive by initial antibody screening to differentiate active versus resolved infection.
    • One-time screening for perinatally exposed infants aged 2–6 months.
    • Immunocompromised individuals.
    One-time HCV genotype testing prior to initiation of direct-acting antiviral (DAA) therapy to guide regimen selection may be reimbursable.
    Quantitative HCV viral load (NAAT) testing may be reimbursable at these timepoints: prior to initiation of DAA therapy; after 4 weeks of DAA therapy; at end of treatment; and at 12, 24, and 48 weeks after completion of treatment.
    Age criterionApplies to all individuals 18 years of age and older
    ScopeIncludes HCV antibody testing (once per lifetime) and HBV triple panel once per lifetime as indicated
    Reimbursement noteMay be reimbursable when billed as indicated and member meets eligibility/benefit criteria
    Components
    HBV triple panel consists of hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (anti-HBs), and total antibody to hepatitis B core antigen (anti-HBc)
    PurposeUsed for initial screening to identify current infection (HBsAg), immunity (anti-HBs), and past or current exposure (anti-HBc)
    Age criterionFor all individuals 18 years of age and older, triple panel once per lifetime may be reimbursable
    Related codesCPT/G code group includes tests for HBsAg and anti-HBs (see coding list)