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Hospital Non-Patient Laboratory Services

Reimbursement Policy:
Hospital Non-Patient Laboratory Services

Effective Date:
01/01/2021

Purpose:
Provide reimbursement guidelines for outpatient laboratory services based on the Centers for Medicare & Medicaid Services (CMS) definition of a non-patient. This policy applies to Participating Hospitals only.

Scope:
All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
  • COB
  • FEP Non-Par
  • ITS Home Par
  • ITS Home Non Par

All Insured and Administrative Services Only (ASO) accounts are included.

Definitions:
Non-Patient (Referred) Laboratory Specimen: per CMS, a non-patient is defined as a beneficiary that is neither an inpatient nor an outpatient of a hospital, but that has a specimen that is submitted for analysis to a hospital and the beneficiary is not physically present at the hospital.

Policy:
Pursuant to CMS guidelines, when a hospital laboratory performs laboratory tests for non-hospital patients (Type of Bill 14X), the laboratory is functioning as an independent laboratory, Horizon BCBSNJ shall consider for reimbursement non-patient laboratory services primarily at 70% of the current CMS Clinical Lab Fee Schedule.

Review a sample of the fees for the 100 most frequently processed CPT® codes in the Horizon Hospital Non-Patient Clinical Lab Fee Schedule. Please note that these codes and fees are subject to change.

Procedure:
Horizon BCBSNJ shall allow the Horizon Hospital Non-Patient Clinical Lab Fee Schedule for hospital non-patient laboratory services. Outpatient laboratory services may be subject to an in-network cost share, if applicable per a member’s benefit plan.

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:
08/24/2020: Policy approved

Policy137_v1.0_08242020

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