Toggle Menu Toggle Site Search

{{ navItem.title }} Overview

Quick Links

{{ navigationConstituentPage.title }}

Reminder: Laboratory Services

Sept. 21, 2021

BlueCross BlueShield of South Carolina and BlueChoice® HealthPlan use Avalon Healthcare Solutions to administer a comprehensive suite of laboratory benefit management services to promote patient access to affordable, high-quality health care. Prior to rendering services, be sure to visit our Medical Policies pages on www.SouthCarolinaBlues.com or www.BlueChoiceSC.com to view the complete medical policy for specific lab tests to ensure the medical policy rule criteria is followed for coverage.

Note: CPT and diagnosis codes listed on each medical policy are not a guarantee of payment and are included only as a general reference tool.  They may not be all-inclusive and must follow the criteria provided.

Benefits of reviewing the medical policies:

  • Prevents delays in claims processing
  • Ensures proper and timely payment
  • Reduces the need for reconsiderations

Below are the policy rule criteria used to determine coverage of laboratory services:

Policy Rule
Definition
Experimental and Investigational Procedure is not covered under the member's benefit due to exclusion
Demographic Limitations Limitations based on patient age
Excessive Procedure Units Total units within and across claims for a single date of service more than necessary
Excessive Units per Period of Time Maximum allowable units within a defined period of time has been exceeded
Insufficient Time Between Procedures Minimum time required before a second procedure is warranted
Rendering Provider Limitations Providers/procedures not permitted in combination
Diagnosis Does Not Support Test Requested Procedure was not appropriate for the clinical situation
Mutually Exclusive Codes The procedure is not valid with other procedures on the same date of service

A few examples of laboratory tests commonly seen and rejected include:

Laboratory Test
Example
Rejection Applied
Vitamin D Testing rendered two weeks after initiation of Vitamin D therapy Insufficient time between procedures
Thyroid Disease Testing of reverse T3, T3 uptake Experimental and investigational
Testosterone Testing saliva for testosterone Experimental and investigational

For the full list of laboratory services commonly provided to our members, click here to view the Laboratory Medical Policy Chart.

To avoid the rejections in the above table and others, it is important to thoroughly read through the medical policies provided to you.  Be sure to follow the specific details outlined in each policy.

If you have any questions, contact Provider Education using the Provider Education Contact Form on one of the above-mentioned websites.

Complementary Content
${loading}