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