Allowable Practice Locations for Pathologists

Administrative Policy:
Allowable Practice Locations for Pathologists

Effective Date:
March 9, 2011

Last Revised Date:
March 3, 2023

Scope:
Hospital-based pathologists who participate in the Horizon BCBSNJ Managed Care Network when affiliated with a network hospital.

Purpose:
To define the allowable practice locations for hospital-based pathologists in the Horizon Managed Care Network.

Definitions:

Hospital-based Physicians: Physicians that practice in the following specialties and provide services within a hospital: anesthesiology, radiology, pathology and Emergency Room (ER) medicine.

Policy:
Horizon BCBSNJ does not recognize office locations or independent clinical laboratory locations as eligible place of service for pathologists. Horizon BCBSNJ only credentials hospital-based pathologists for our managed care network, using the criteria set forth in the Credentialing and Recredentialing Policy for Participating Physicians and Healthcare Professionals. The participation status of a hospital-based pathologist is directly tied to his/her affiliation with the hospital-based group. The participating status of a hospital-based pathologist is not portable to an office setting or independent clinical laboratory setting.

Pathology claims submitted for services rendered to Horizon BCBSNJ managed care members in an "office" setting or independent clinical laboratory setting are not eligible for reimbursement.

HCM-PP-HCS-001-0723