This is only a notification of the policy that will be in effect on 06/23/2010. For the current version of this policy, click the following link: 00.01.41, STAT Laboratory Tests Performed in the Outpatient Hospital Setting for Health Maintenance Organization (HMO) and Point of Service (POS) Products.
In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
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.