Outpatient Laboratory Claims: Referring Practitioner Required
Effective Date:
November 15, 2019
Purpose:
Provide guidelines for clinical laboratory services that require the reporting of the referring practitioner on claim submissions. This applies to participating and non-participating providers.
Scope:
All products are included, except
- Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap)
- COB
- FEP Non-Par
- ITS Home
- MPL
All Insured and Administrative Services Only (ASO) accounts are included.
Policy:
In accordance with Centers for Medicare and Medicaid Services (CMS) guidelines, Horizon BCBSNJ requires that claims for clinical laboratory services report the referring practitioner on the claim submission.
Procedure:
Horizon BCBSNJ shall deny laboratory services when a qualified referring practitioner is not reported on the claim submission. In denied instances, there shall be no member liability.
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:
07/22/2019: Policy approved
Policy127_v1.0_07292019
