by Jared Staheli
July 9th, 2015
Medicare recognizes that specimens drawn or collected by one laboratory are sometimes referred to another laboratory for testing. Payment for a Medicare-covered, referred laboratory service may be made under the rules established in Chapter 15 §40.1.
The rules specified Chapter 15 §40.1 do not apply to services performed in a physician office laboratory or a qualified hospital laboratory. Both circumstances are entirely outside the scope of all sections concerning referral laboratory services.
Every carrier shall process a claim for a referred laboratory service if submitted by an independent clinical laboratory with a physical presence within the carrier’s jurisdiction, notwithstanding that the referred laboratory service may have been performed outside of its jurisdiction.
Every carrier shall maintain the clinical laboratory fee schedules for each carrier jurisdiction and be able to process claims using those fee schedules.
Every carrier shall base payment for a referred service on the fee schedule for the jurisdiction in which the service was performed, i.e., where the test was performed. An exception to this rule allows a payment for a service that is carrier-priced to be based upon the price developed by the carrier processing the claim.
Every carrier that has previously assigned “reference use only” PINs to out-ofjurisdiction laboratories for the purpose of their billing referred services shall cancel such “reference-use-only” PINs.
Carriers must use the numerical locality codes specified in 50.4 to identify the appropriate clinical diagnostic laboratory fee schedule for use in pricing a referred laboratory service.