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New Reimbursement Policy: Hospital Non-Patient Clinical Lab Fee

Effective January 1, 2021 Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) will implement a new policy and fee schedule for non-patient laboratory services, Horizon BCBSNJ Hospital Non-Patient Clinical Lab Fee Schedule. This policy will change the way we reimburse certain laboratory claims submitted by network hospitals for members with commercial and Medicare Advantage plans.

The policy aligns the processing and reimbursing of outpatient laboratory services claims submitted by our network hospitals with that of the Centers for Medicare & Medicaid Services (CMS) and their definition of a “non-patient.” According to CMS, a non-patient is a beneficiary who is not physically present as an inpatient or outpatient at a hospital, but has had a laboratory specimen submitted for analysis to a hospital. Reimbursement under your Network Hospital Agreement describes payment for services provided to Horizon BCBSNJ members who are registered as an inpatient or outpatient at the hospital.

When a hospital laboratory performs laboratory tests for a non-patient, the laboratory functions as an independent laboratory. Claims submitted by hospitals for outpatient laboratory services rendered on and after January 1, 2021 to non-patients (type of bill 14X)¹ will be paid according to the Horizon BCBSNJ Hospital Non-Patient Clinical Lab Fee Schedule.

We encourage you to review the content of the Horizon BCBSNJ Hospital Non-Patient Clinical Lab Fee Schedule policy, in addition to all other policies, within our Reimbursement Policies & Guidelines at HorizonBlue.com/reimburse.

¹Use of bill type 14X is self-monitored and misuse of bill type 14X can lead to recapture of reimbursement, penalties and/or termination of the Independent Laboratory Participating Agreement.


Fee Schedule Inquiry Tool

Fee schedule information is available on our Fee Schedule Inquiry tool.

To access, log into NaviNet.net, select Horizon BCBSNJ from the My Health Plans menu and:

  • Mouse over Claim Management
  • Select Fee Request Inquiry

To view allowances for specific codes:

  • Select your Billing Provider number, County and Specialty
  • Enter the desired CPT® and/or HCPCS codes
  • Select Submit

CPT® is a registered mark of the American Medical Association.

Published on: October 1, 2020, 03:28 a.m. ET
Last updated on: June 4, 2021, 00:53 a.m. ET