UnitedHealthcare has implemented a reimbursement policy that applies to all laboratory services to align with Centers for Medicare & Medicaid Services (CMS) and Clinical Laboratory Improvement Amendments (CLIA) requirements. The effective date for the policy was Nov. 1, 2016 for participating providers and Aug. 1, 2016 for non-participating providers. The reimbursement policy applies to UnitedHealthcare commercial and Medicare Advantage members claims submitted on either a CMS 1500 claim form or HIPAA 5010 837 P claim file.
The policy requires that all claims for laboratory services include the CLIA number for the servicing care provider. The lab servicing provider’s physical address also will be required if the address differs from the billing provider’s address noted on the claim. The billing or servicing provider’s address must match the address associated with the CLIA ID number. CLIA regulatory requirements vary by the kind of test each laboratory conducts. Tests are categorized as waived, moderate complexity or high complexity. CLIA requires all lab testing sites to have one of the following certificates to legally perform clinical laboratory testing.
Types of CLIA Certificates:
- Certificate of Waiver
- Certificate of Registration
- Certificate of Accreditation
- Certificate for Physician-Performed Microscopy
- Certificate of Compliance
For more information on CLIA requirements and test complexity categories, go to CLIA website at cms.hhs.gov/clia/.