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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 at 70% of the Current Horizon Hospital Non-Patient Clinical Lab Fee Schedule.

Horizon shall not consider for reimbursement any procedure codes on the non-patient bill types (14X) whose description implies that the member must be present for the service to be performed. Services such as venipuncture, procedure code 36415, or other services requiring the presence of the member shall not be considered eligible for reimbursement on non-patient bill types.

If a code is eligible for a Technical Component (TC) modifier, the code will pay at the TC rate regardless of whether the modifier is used. This includes, but is not limited to the following procedure codes: 88104, 88106, 88108, 88112, 88120, 88121, 88125, 88160, 88161, 88162, 88172, 88173, 88177, 88182, 88300, 88302, 88304, 88305, 88307, 88309, 88311, 88312, 88313, 88314, 88319, 88323, 88331, 88332, 88333, 88334, 88341, 88342, 88344, 88346, 88348, 88350, 88355, 88356, 88358, 88360, 88361, 88362, 88364, 88365, 88366, 88367, 88368, 88369, 88373, 88374, 88377, 88380, 88381, 88387, 88388.

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
4/26 2021: Clarified that services with a definition that implies the member must be present for services will not be reimbursed. Also clarified that for procedure codes eligible for global and TC reimbursement that only TC rate will be reimbursed for non-patient services.

Policy137_v1.0_08242020

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