Lighthouse’s RCM Solutions Team was recently made aware that Blue Cross Blue Shield of Alabama is conducting overpayment reviews for infectious disease testing that could result in takebacks for impacted clinical laboratories.
The message (available below) indicates the payer intends to audit claims for detecting infectious disease by nucleic acid due to it being an uncovered service dating back to November 2013. If you click on the link in the notice below, it shows the review period goes into effect beginning July 26, 2022. If BCBS of Alabama initiates an overpayment review on claims with these dates of service, it may result in takebacks. Any lab doing business with BCBS of Alabama needs to be aware of this change.
This policy includes both Polymerase Chain Reaction (PCR) and Next-Generation Sequencing (NGS) since they use the methodology listed in this policy, and the same CPT codes are utilized. This policy states that unless the pathogen is identified in this policy, it will not be covered. Any pathogen that uses 87797, 87798, and 87799 will not be covered. The policy does show that some infectious disease is covered, but this policy will be detrimental for wound and UTI. The policy is showing that they will cover Gardnerella, but not vaginitis panels or full STI panels.
If you’re contacted for an overpayment review and are seeking assistance complying with the request, or if you’d like to discuss reimbursement strategies for infectious disease testing, contact us today for a free consultation.
Full notice from BCBS of Alabama below:
Medical Policy 548, Identification of Microorganisms Using Nucleic Acid Probes
Blue Cross and Blue Shield of Alabama does not provide benefits for infectious agent detection by nucleic acid (DNA or RNA, not otherwise specified) using a direct or amplified probe technique with or without quantification of viral load.
CPT codes 87797, 87798 and 87799 are considered investigational and are not covered.
Select the appropriate code per Medical Policy 548, Identification of Microorganisms Using Nucleic Acid Probes.
Note: This medical policy has been in effect since November 2013. Claims filed that do not meet this policy will be subject to overpayment review.
View our medical and drug policies at AlabamaBlue.com/providers/policies.