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Lab Panel Rebundling

Reimbursement Policy:
Lab Panel Rebundling

Effective Date:
March 12, 2012

Last Revised Date:
November 30, 2015

Purpose:
To provide guidelines for reimbursement when two or more, but not all, components of an automated laboratory panel are reported on the same date of service by the same provider. The payment for the individual components should not exceed the payment of the full panel. This policy shall apply to participating and non-participating professional providers and Outpatient UB claims when CPT/HCPCS codes are included.

Scope:
All products are included, except:

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
  • COB
  • ITS Home PAR and Non Par
  • ITS Host Medicare Advantage Non-PPO
  • ITS Host Medicare Advantage PPO Non Par
  • Participating Facilities
  • MPL Non Par
  • FlexLink
  • FEP Facility Claims

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

Definitions:
Automated Test Panels: Individual laboratory tests that clinical laboratories typically perform at the same time on the same automated equipment. CPT-4 describes these laboratory tests as Organ or Disease oriented panels and identifies the component tests that make up a particular panel.

Policy:
When multiple components of a laboratory panel are reported on the same date of service, the payment for the individual components should not exceed the payment amount of the panel.

Procedure:
Deny two or more automated laboratory test components reported when the sum of the value-based laboratory test components exceeds the value of an all-inclusive automated test panel. The closest related automated test panel code that is comprised of components in common with those submitted on the claim is added to the claim, resulting in the component procedures being disallowed.

In denied instances where the provider is participating, there shall be no member liability.

In denied instances where the provider is non-participating, the member’s 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.

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

Policy 062_v2.0_12182015