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Outpatient Laboratory Claims: Referring Practitioner Required

Effective Date:
November 15, 2019

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.

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. 

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.

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.


07/22/2019: Policy approved