Billing for diagnostic testing

[nwaite]

Hi Michele,

I am setting up billing for a new diagnostic lab.  We will have patients across the U.S. so will be working with many different carriers.  We are in the process of enrolling with our local Medicare carrier.  When we receive a case for a patient with Medicare who is outside of the state where our lab is, will we send claims to the address on the patient's card or to our local carrier?

Thanks!

[Michele]

If you are performing the tests in your lab then you bill your Medicare for the services, no matter where the patient lives.

Michele

[nwaite]

Hi Michele,

Thank you for the previous response.  The credentialing process for clinical laboratories does not seem to be as straightforward as for individual providers.  When I speak with payers, they often do not know which applications we should be completing as an independent lab.  As a lab, I believe we cannot complete credentialing applications via CAQH (I saw this on another post on this site) - is this correct?  Do you have any recommendations regarding how I can approach payers for credentialing requirements for a lab?

Also, is credentialing only required if we want to be in-network with the payer or is credentialing required regardless.  Have you heard of payers coming to do inspections at the lab site before approving the application?  I've heard Medicare will do this, but I'm unsure about other commercial payers.

Thanks,

Nancy

[Michele]

You do not do a CAQH application for a lab.  The CAQH is for individual practitioners.

I'm actually going thru the same thing.  I am finding that you have to call each carrier and ask.  Most are telling us that they don't credential labs, they contract with them. 

Even if you don't want to be in network I would contact them to see if you still need to contract in order for claims to be paid.

Michele

[nwaite]

Thanks again!

Our lab is determining a risk score based on a series of tests.  Is there a regulation requiring us to disclose on our requistion form that the physician is ordering a panel of tests?  If you have heard of such a regulation, do you know of resources I can access to research it?

Thanks!

[Michele]

I am not sure if there is any regulation requiring you to disclose your requisition form.  I'm not even sure where to point you to find out.  You could try the state insurance commissioner for your state.  Or maybe someone else on the forum could help us out.

Michele

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