Carrier Claims Processing - Physicians (Rev. 1, 10-01-03)

by  Jared Staheli
July 9th, 2015

If a physician or medical group furnishes laboratory tests in an office setting and it is appropriate for them to be performed in the physician’s office, no further development of the source of the laboratory tests is required.

If a claim or physician’s bill raises a question as to the source of a laboratory test and it cannot be resolved from available information, carriers must request the source of the laboratory service from the physician.

If the clinical laboratory test is subject to the laboratory fee schedule, carriers must pay only the person or entity that performed or supervised the performance of the test. However, carriers may also pay one physician for tests performed or supervised by another physician with whom he/she shares a practice, i.e., the two physicians are members of a medical group whose physicians submit claims in their own names rather than in the name of the group. Where the medical group submits claims in the name of the group for the services of the physician who performed or supervised the performance of these tests, carriers must pay the group. Regardless of who submits the claim, assignment is required for payment. See §50.2.1 below.

References:

Carrier Claims Processing - Physicians (Rev. 1, 10-01-03). (2015, July 9). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/carrier-claims-processing-physicians-rev-1-10-01-03-27188.html

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