Laboratory Billing Compliance Guidelines
In accordance with our company culture of integrity and professionalism, we follow all federal, state, and local laws governing clinical laboratory billing compliance. A laboratory order by a physician or credentialed clinician is considered an official request for laboratory testing. A compliant laboratory or requisition is considered a legal document that grants permission to the laboratory to bill the patients’ insurance.
CMS (Center for Medicare and Medicaid Services) is the governing body who creates, revises, and enforces compliance guidelines for laboratory orders and requisitions. Insurance carriers require compliant orders before payment is made. CMS and by independent insurance carriers initiate periodic audits of laboratory documentation at any time. Each audit requires the laboratory to produce a copy of the original compliant laboratory order and/or test requisition.
For your convenience the list below outlines what is required by CMS and by independent insurance carriers for an order or requisition to be considered compliant.
Requirements for a compliant lab order:
- Patients full legal name
- Patients DOB
- Patients last 4 of SS# (not required but helpful)
- Ordering Physician & NPI #
- Ordering Physicians signature
- Valid ICD-10 diagnosis code.
- Patients insurance (if applicable)
- ICD-10 Diagnosis Codes (commonly used)
- Behavioral Health ICD-10 Codes (commonly used)
- ICD-10 Diagnosis Codes (problematic tests)
- ADL Non-covered ICD-10 Codes for All Lab NCD’s
CMS Law Updates
The Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is issued by providers (including independent laboratories, home health agencies, and hospices), physicians, practitioners, and suppliers to Original Medicare (fee for service – FFS) beneficiaries in situations where Medicare payment is expected to be denied. The ABN is issued in order to transfer potential financial liability to the Medicare beneficiary in certain instances.
Billing for Patients
ADL’s live, experienced, in-house clinical laboratory billing compliance representatives are available to assist. The billing department supports all compliance guidelines when submitting claim(s) to your insurance. Our billing team will make every attempt to bill your insurance carrier, when applicable.
Upon processing, your insurance company will send you an ‘Explanation of Benefits’ for your records. This is only an explanation of services charged to your insurance carrier. THIS IS NOT A BILL
Reasons you may receive a bill from ADL:
- Your insurance coverage is capitated to another laboratory
- You have outstanding deductibles and co-payments with your insurance carrier
- The test ordered is not covered by your insurance carrier
If you receive a bill from us and have questions, we are here to assist. For better service, please have your insurance information, your explanation of benefits, and your bill available when you call. Payment plans are available for qualifying balances.
To ensure accuracy, if you do not see your insurance listed, or are unsure of your insurance coverage, contact an ADL Billing Representative at 866-465-6763 x 264 for more information.