The new Medicare Advantage policy portfolio that includes this policy bulletin will become effective on 01/01/2015.
Precertification and referrals are not required for the STAT lab tests listed in Attachment A. These tests may be performed by any participating hospital laboratory, provided that a participating provider (ie, the individual's primary care physician [PCP] or specialist) requests the STAT lab test via a written order.
Lab tests that are not included in Attachment A require precertification if they are to be performed on a STAT basis. When ordered in conjunction with STAT lab tests, routine lab tests require precertification in order to be eligible for additional reimbursement consideration.
Routine lab tests and those not listed in Attachment A must be directed to the PCP-designated laboratory site for Health Maintenance Organization (HMO) and Point-of-Service (POS) products.
In geographic areas with a capitated lab program, STAT lab tests listed in Attachment A and performed in an outpatient hospital setting that is the member's designated cap site are included in the capitation payment and are, therefore, not eligible for separate reimbursement.
At times, it may be necessary for providers to perform specific laboratory tests to obtain immediate results to assist in determining the individual's course of treatment. These tests are defined as STAT lab tests and are performed in the outpatient hospital setting.