Carrier Claims Processing - Examples of Reference Laboratory Jurisdiction Rules (Rev. 85, 02-06-04)

by  Jared Staheli
July 10th, 2015

EXAMPLE 1:

Scenario 1:

An independent laboratory located in Oregon performs laboratory services for physicians whose offices are located in several neighboring States. A physician from Nevada sends specimens to the Oregon laboratory.

Jurisdiction:

The carrier in Oregon has jurisdiction.

EXAMPLE 2:

Scenario 2:

American Laboratories, Inc., is an independent laboratory company with branch laboratories located in Philadelphia, PA and Wilmington, DE, as well as regional laboratories located in Millville, NJ and Boston, MA.

The Philadelphia laboratory receives a blood sample from a patient whose physician ordered a complete blood count, a basic metabolic panel and a B12 and folate. The Philadelphia laboratory performs the complete blood count, but the basic metabolic panel is performed at the Millville laboratory, while the B12 and folate is performed at the Boston Laboratory.

Jurisdiction:

The Pennsylvania carrier may retain jurisdiction for processing the claim for all of the services. The local carrier servicing Boston and/or Millville may have jurisdiction for processing their claims if those laboratories bill for the services they perform, but the Philadelphia laboratory is barred from billing for the services that Boston and Millville submit for payment.

EXAMPLE 3:

Scenario 3:

Same relationships as in Example 2. American Laboratories, Inc., is an independent laboratory company with branch laboratories located in Philadelphia, PA and Wilmington, DE, as well as regional laboratories located in Millville, NJ and Boston, MA.

This time the Wilmington laboratory draws a blood specimen from a patient whose physician has ordered a blood culture. The Wilmington laboratory then sends the specimen to the Boston laboratory, which performs the required test.

Jurisdiction:

The carrier processing claims for providers/suppliers located in Delaware may retain jurisdiction for processing the claim. If the laboratory in Boston chooses to bill for the service to the Massachusetts carrier, then the Wilmington laboratory may not bill for the service.

References:

Carrier Claims Processing - Examples of Reference Laboratory Jurisdiction Rules (Rev. 85, 02-06-04). (2015, July 10). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/carrier-claims-processing-examples-of-reference-laboratory-jurisdiction-rules-rev-85-02-06-04-27205.html

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