January 1, 2003
Last Revised Date:
May 24, 2021
This policy outlines our guidelines for the reimbursement of pre-admission testing (PAT) services.
All products are included, except
- Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
All Insured and Administrative Services Only (ASO) accounts are included.
- Pre-Admission Testing: Includes any service performed on the day of, or within the 72-hour period prior to the day of, a patient’s planned inpatient admission or same day surgery service.
Horizon BCBSNJ considers all medically necessary outpatient services provided to that member by the admitting hospital or associated or affiliated entity (including, but not limited to: part of hospital system, affiliated ambulatory surgery center, urgent care center), on the day of, or in the 72-hour period prior to the day of that member’s planned admission or same day surgery to be pre-admission testing.
This includes, but not limited to, COVID-19 testing for all planned inpatient admissions and same day surgery services.
PAT services performed on the day of, or in the 72-hour period prior to the day of, that member’s planned inpatient admission or same day surgery service are NOT considered for separate reimbursement.
Ambulance services provided on the day of, or in the 72-hour period prior to the day of, a patient’s planned inpatient admission or same day surgery service are not considered pre-admission testing.
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
04/15/2011: Policy approved
02/06/2012: Update to SDS criteria to allow separate reimbursement for same claim/same DOS PAT services.
07/09/2014: Revised and reformatted content for clarity per Legal.
07/30/2015: Removed “by an entity owned or operated by the hospital…” from Policy: section. Revised Procedure: section, Paragraph 2 “admissions may be…”
08/04/2020: Added reference to COVID-19 testing and “associated or affiliated entity” language within the Policy: section.
05/24/2021: Updated to remove from Definition and policy sections the statement: “related to a patient’s planned inpatient admission or same day surgery”. Removed from Procedure section second paragraph, “Outpatient Services that are not…”