24-918 Avoid Unnecessary Claims Denials and Processing Delays for In-Office Lab Testing

Date: 09/05/24

Follow this new policy effective November 11, 2024, to bill physician’s office lab testing

Refer to the information below to learn about a new payment policy from Health Net, on behalf of CalViva Health. This policy will help you correctly bill for certain services. This information applies for all physicians, as well as Enhanced Care Management physicians, Community Supports physicians and behavioral health physicians. 

Easy access to payment policies

The Plan’s payment policies are viewable on a dedicated webpage on the publicly facing provider website. The policies are easy to find and display according to line of business or product.

In addition to easy access to the Plan’s medical policies, you can also find the Plan’s payment policies at the same location at provider webpage > Resources For You.

Access the new payment policy webpage.

The Plan publishes payment policies to inform physicians and other providers about acceptable billing practices and reimbursement methodologies for certain procedures and services. The Plan will apply these policies as medical claims reimbursement edits within its claims adjudication system. This is in addition to all other reimbursement processes that the Plan currently employs.

The Plan believes that publishing this information will help physicians and other providers bill claims more accurately, therefore reducing unnecessary denials and delays in claims processing and payments.

The policies address:

• coding inaccuracies,
• diagnosis-to-procedure code mismatch,
• inappropriately modified procedures,
• unbundling,
• incidental procedures,
• duplication of services, and
• health plan-specific payment rules for procedures and services.

The policies are based on medical literature and research, and industry standards and guidelines as published and defined by the American Medical Association’s Current Procedural Terminology (CPT^®), Centers for Medicare & Medicaid Services (CMS) and public domain specialty society guidance, unless specifically addressed in the fee-for-service provider manual published by California or in regulations.

Note, actual CPT codes to be included or excluded in the payment policies are not all-inclusive and may be subject to change.

Payment policy chart

The following chart lists the policy number, policy name, a description of the policy, applicable provider types, and applicable lines of business.

Policy number	Policy name	Description of policy	Applicable provider	Line of business
CC.PP.055	Physician’s Office Lab Testing	To ensure higher quality laboratory tests are performed in the correct setting, in-office laboratory testing will only be allowed for the CPT and HCPCS codes listed in the Short Turnaround Time (STAT) laboratory code list included in this policy. These are tests that are needed immediately in order to manage medical emergencies or urgent conditions. To this end, specific clinical laboratory tests have been designated as appropriate to be performed in the office setting. Reimbursement for in-office laboratory procedures is limited to those codes listed in the STAT laboratory procedure code list (see the Coding and Modifier Information section in the policy). Laboratory procedures not included on the STAT lab list should be referred to an independent, contracted lab provider. Sensitive services testing can continue to be performed in the physician’s office.	Physicians	Medi-Cal, including CalViva Health

 

This information applies to Physicians, Community Supports (CS) Providers, Enhanced Care Management (ECM) Providers, and Behavioral Health Providers.

This information applies to Medi-Cal in Fresno, Kings and Madera counties.