Duplicate Claim Logic for Independent Laboratory Services

Reimbursement Policy:
Duplicate Claim Logic for Independent Laboratory Services

Effective Date:
February 25, 2019

Purpose:
Provide guidelines to implement and restrict payment for duplicate services performed in an independent lab setting that have been previously processed for payment to different providers.

Scope:
All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
  • COB
  • ITS Home In-Network
  • FEP
  • SHBP non MA

All Insured Individual, Commercial medical plans, and Medicare Advantage Plans, are included.

ASO accounts will be included as an Opt-In option for additional claims editing on an account-by-account basis

Policy:
Horizon BCBSNJ shall not consider for reimbursement a procedure code billed in an independent lab setting (POS 81) when the same procedure code is billed on the same date of service by a different provider ID/specialty type.

Procedure:
Horizon BCBSNJ shall deny claim lines reported in an independent lab setting (POS 81) when the same procedure code is billed by a different provider/specialty type.

In instances where the provider is participating, no member liability shall apply.

In instances where the provider is not participating, member liability shall be up to the provider’s charge.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

History:
10/25/2017: Policy approved

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

Policy 107_v1.0_10252017