Pass-through billing - Chapter 10, 2021 UnitedHealthcare Administrative Guide

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.

Clinical Laboratory Improvement Amendments (CLIA) requirements/reimbursement policy requirements/reimbursement policy

We only reimburse for laboratory services that you are certified to perform through the federal CLIA. You must not bill our members for any laboratory services if you don’t have the applicable CLIA certification.

In-office laboratory tests and CLIA waived tests

Care provider offices granted a CLIA Certificate of Waiver may conduct a limited number of tests in-house.

As defined by CLIA, waived tests are simple tests with a low risk of an incorrect result. Sites that perform only waived testing must have a CLIA Certificate of Waiver and follow the manufacturer’s instructions; other CLIA requirements do not apply to these sites. To determine if the test being performed has been approved for Certificate of Waiver status, 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 UHCprovider.com.

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.

Claim payment is subject to our payment policies and medical policies, which are available at UHCprovider.com/policies or upon request to your network management contact.