Pass-through Billing / CLIA Requirements / Reimbursement Policy
If you are a physician, practitioner, or medical group, you may only bill for services that you or your staff perform. Pass-through billing is not permitted and may not be billed to our members.
We only reimburse for laboratory services that you are certified to perform through the Federal Clinical Laboratory Improvement Amendments (CLIA). You must not bill our members for any laboratory services for which you lack the applicable CLIA certification.
In-Office Laboratory Tests and CLIA Waived Tests
Limit your laboratory tests done in your office to only those urgently needed. There is a list of approved in-office tests. You must make sure the test is on the CLIA Waived Test List.
All other laboratory tests require a referral to a participating or capitated laboratory. You can find a list of approved codes on CMS.gov > Regulations & Guidance > Legislation > Clinical Laboratory Improvement Amendments. Participating laboratories are listed on our Labs of Choice identified by the Laboratory Benefit Management Program.
Note: Some plans are capitated for laboratory services. The capitated laboratory care provider must be used to perform services not allowed in the care provider’s office.
In addition, care provider offices granted a CLIA Certificate of Waiver, may conduct a limited number of tests in-house. Tests that may conduct under a certificate of waiver must meet the descriptive criteria specified in our Laboratory Benefit Management Program Administrative Protocol and or CMS.gov > Regulations & Guidance > Legislation > Clinical Laboratory Improvement Amendments.
Claim payment is subject to our payment policies and medical policies, (view our Policies) or upon request to your Network Management contact.