This article is for:
- Providers and their office staff who order clinical laboratory testing for our members
- Servicing clinical laboratories
Please share with your authorization department and billing department
We are seeing an increase in denied claims for clinical laboratory tests. This may be because the test:
- Didn’t get authorized (ordering providers must submit authorization requests)
- Doesn’t meet medical necessity criteria
- Isn’t covered
- Is being performed by an out-of-network laboratory.
This leads to higher costs for your patients and both payment delays and financial liability for servicing laboratories. We’ve also received an increased number of appeals that could be avoided by taking the required steps shown below.
You can help our members, your patients, to receive the covered laboratory testing they need by following Blue Cross policies. Here are some things you can do:
- Always check member benefits and eligibility first to confirm if a test is covered. Some tests aren’t covered at all because a less-expensive, clinically effective test may be available.
- Review our medical policies to learn about medical necessity requirements for coverage. If authorization is required, the ordering provider should request it.
- Genetic testing and molecular diagnostics require authorization with Carelon Medical Benefits Management.
- Ordering providers must submit the authorization request to Carelon. If approved, you’ll receive notification that includes the name of the approved test, the units approved, and the CPT code(s). A copy of the approved authorization should be attached to your lab requisition form. This will help prevent miscommunication on what test has been approved and smooth claims processing.
- Servicing providers should also verify that an authorization is in place before performing the service so you know your claim will pay.
- Refer to our Genetic Testing page for details on the prior authorization program.
- Direct testing to participating, in-network clinical laboratories.
- Out-of-network lab services are generally not covered for HMO and EPO members unless a specific medical necessity exception has been approved by Blue Cross. PPO members may experience significantly higher out-of-pocket costs from out-of-network laboratories.
- Make sure that the CPT code on the claim matches the test that was approved and performed.
Thank you
Complying with these policies is part of your contract with us and is the best way to help reduce denied claims and appeals, lower costs for members, and facilitate proper payment for covered services.
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