Does CalViva Health require prior authorization for 36416?

CalViva Health lists 36416 on CalViva Health CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

Does Community Health Plan of Imperial Valley require prior authorization for 36416?

Community Health Plan of Imperial Valley lists 36416 on Community Health Plan of Imperial Valley CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

What insurance policy changes affect CPT 36416?

There are 11 tracked policy changes affecting CPT 36416, including updates from Blue Cross Blue Shield of Vermont, Independence Blue Cross, Capital Blue Cross. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for CPT 36416?

Payers that have issued tracked updates for CPT 36416 include: Blue Cross Blue Shield of Vermont, Independence Blue Cross, Capital Blue Cross, BCBS Illinois, BCBS New Mexico, Indiana Medicaid (IHCP), Nevada Medicaid, Aetna.

How do I get notified when CPT 36416 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to CPT 36416. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for CPT 36416?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

PAYER POLICY CHANGES

36416 Insurance Policy Changes

CPT 36416 is referenced in 11 tracked payer policy changes from Blue Cross Blue Shield of Vermont, Independence Blue Cross, and 6 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 36416 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Blue Cross Blue Shield of Vermont · Effective Dec 1, 2026High impact
Preventive Care Reminder Sent to Members
Members receive the preventive services listed here at no cost when they align with USPSTF A- and B-rated services, ACIP vaccine recommendations, HRSA infant, child, adolescent and women's preventive guidelines, and Vermont state mandates. Covered procedure and diagnosis codes are listed for screenings, counseling, vaccines and preventive medications for children, adults and pregnant members, and some services require prior approval. Recent revisions add a Pre-Diabetes Preventive Interventions section for adults 18 and older, split mammography into diagnostic, ultrasound and MRI sections, and add pregnancy diagnosis codes effective 12/01/2026.
Independence Blue Cross · Effective Nov 2, 2026High impact
00.01.52ad, Bundled Procedure Codes
Independence Blue Cross has updated policy 00.01.52ad to clarify that venipuncture (CPT codes 36400, 36405, 36406, 36410, 36415, 36416, 36591, 36592) is not eligible for separate reimbursement to outpatient facilities when performed incidental to laboratory services. These codes are now added to Attachment D, meaning they cannot be billed separately when reported with other services on the same date by the same provider.
Capital Blue Cross · Effective Sep 1, 2026High impact
AB2026-08-001 Updates and new information
Capital Blue Cross issued a multi-topic administrative bulletin with four key changes: (1) new Availity electronic appeals training available, (2) new venipuncture reimbursement policy effective October 1, 2026 requiring separate lab facility billing, (3) retirement of global obstetrical policy with transition to visit-based billing September 1–December 31, 2026, and (4) updates to preauthorization requirements for specific chemotherapy and durable medical equipment codes across multiple plan types.
Independence Blue Cross · Effective Nov 2, 2026Medium impact
00.01.52ad, Bundled Procedure Codes
Independence Blue Cross updated policy 00.01.52ad effective 11/02/2026 to clarify that venipuncture (CPT codes 36400, 36405, 36406, 36410, 36415, 36416, 36591, 36592) is not eligible for separate reimbursement when performed incidental to laboratory services at outpatient facilities. The billing team must stop billing these codes separately when submitted with lab work on the same date and ensure claims are submitted correctly to avoid denial.
BCBS Illinois · Effective Jul 1, 2026Medium impact
See Updates to Lead Screening Requirements for All Illinois Children
Effective July 1, 2026, Illinois expanded childhood blood lead testing requirements to all children (previously Medicaid-only). All children must now be tested at 9–12 months and 24 months. Providers should use appropriate CPT and ICD-10-CM codes for blood lead analysis, collection, and abnormal results to ensure proper billing and compliance with quality measures.
BCBS New Mexico · Effective May 21, 2026Medium impact
Screen Medicaid Members for Lead Exposure Before Their Second Birthday
Blue Cross Blue Shield of New Mexico requires blood lead screening for all Medicaid children at 12 and 24 months of age, with catch-up testing for children 24-72 months with no previous screening. Specific CPT and ICD-10 codes must be used for proper billing and documentation.
BCBS Illinois · Effective May 21, 2026Medium impact
Screen Medicaid Members for Lead Exposure Before Their Second Birthday
Blue Cross Blue Shield of Illinois now requires blood lead screening for all Medicaid children at 12 and 24 months of age, with catch-up testing for children 24-72 months old who have never been screened. Proper documentation and specific CPT/ICD-10 coding is required for compliance with quality measures.
Indiana Medicaid (IHCP) · Effective Jan 1, 2026Medium impact
BT2025160: IHCP updating outpatient reimbursement rates for procedure codes 36415 and 36416
Indiana Health Coverage Programs (IHCP) is updating outpatient reimbursement rates for blood collection procedures effective January 1, 2026. CPT 36415 (needle insertion into vein for blood collection) will reimburse at $9.09 and CPT 36416 (skin puncture for blood collection) will reimburse at $3.77.
Nevada Medicaid · Effective Oct 17, 2025Medium impact
Clarification to Web Announcement 3692: Attention Providers Serving Healthy Kids or Nevada Check Up Recipients: Lead Testing Guidance according to the American Academy of Pediatrics (AAP) Bright Future’s Periodicity Schedule
Nevada Medicaid clarifies that blood collection codes 36415 (venous) and 36416 (capillary) cannot be billed together on the same date when performing blood lead tests (83655). Providers can still perform lead testing in-house with CLIA waiver or refer to external labs.
Nevada Medicaid · Effective Aug 8, 2025Medium impact
Attention Providers Serving Healthy Kids or Nevada Check Up Recipients: Lead Testing Guidance according to the American Academy of Pediatrics (AAP) Bright Future’s Periodicity Schedule
Nevada Medicaid clarifies lead testing guidelines for pediatric patients, specifying that blood lead assessments are included in routine EPSDT/Healthy Kids checkups and outlining specific CPT codes for reimbursement when separate lead testing is medically indicated.
Aetna · Identified Aug 15, 2026Medium impact
Celiac Disease Laboratory Testing (CPB 0561, reviewed 2026-08-03)
Serological testing for IgA anti-human tissue transglutaminase (TTG), IgG and IgA deamidated gliadin (DGP), and IgA anti-endomysial (EMA) antibodies is medically necessary as a preliminary diagnostic test for persons with symptoms suggestive of celiac disease, to monitor response to a gluten-free diet, to screen first-degree relatives of individuals with celiac disease, and to screen persons with type 1 diabetes. HLA-DQ2 and HLA-DQ8 genetic testing is medically necessary for listed situations, including seronegative persons with equivocal small bowel histology findings (Marsh I-II), evaluation of persons on a gluten-free diet in whom no serologic testing was performed before starting it, and persons with Down syndrome. Anti-gliadin antibody (AGA) and anti-reticulin antibody (ARA) testing, the Prometheus Celiac Plus Panel, and HLA genotyping for screening persons with type 1 diabetes are experimental, investigational, or unproven.

Watch 36416

Get one email when a payer policy names 36416, a payer adds or drops it from a prior auth list, or Medicare changes its NCCI pairs, unit limit, payment or coverage articles.

See every payer rule for 36416

Prior authorization lists, coverage criteria, NCCI edits and Medicare coverage articles for 36416 in one place.

See every payer rule

Get alerts for changes like this

Save a search and get email alerts when a new policy change matches your filters: daily or weekly, your choice, on every plan.

Create a free alert How Policy Monitoring works

Preventive Care Reminder Sent to Members

00.01.52ad, Bundled Procedure Codes

AB2026-08-001 Updates and new information

00.01.52ad, Bundled Procedure Codes

See Updates to Lead Screening Requirements for All Illinois Children

Screen Medicaid Members for Lead Exposure Before Their Second Birthday

Screen Medicaid Members for Lead Exposure Before Their Second Birthday

BT2025160: IHCP updating outpatient reimbursement rates for procedure codes 36415 and 36416

Clarification to Web Announcement 3692: Attention Providers Serving Healthy Kids or Nevada Check Up Recipients: Lead Testing Guidance according to the American Academy of Pediatrics (AAP) Bright Future’s Periodicity Schedule

Attention Providers Serving Healthy Kids or Nevada Check Up Recipients: Lead Testing Guidance according to the American Academy of Pediatrics (AAP) Bright Future’s Periodicity Schedule

Celiac Disease Laboratory Testing (CPB 0561, reviewed 2026-08-03)

Prior authorization required