Carrier Claims Processing - Reporting of Pricing Localities for Clinical Laboratory Services (Rev. 85, 02-06-04)

by  Jared Staheli
July 10th, 2015

Carriers shall report to the common working file (CWF) new State pricing localities (positions 58 and 59 on the carrier record) indicated on the Clinical Diagnostic Laboratory fee schedule for any reference laboratory service billed with a HCPCS 90 modifier. If the laboratory test billed is not a reference laboratory service, the Carrier Locality (location 11-12) on the Clinical Diagnostic Laboratory fee schedule should be forwarded to the CWF. For dates of service on or after April 1, 2004, CWF will not edit clinical laboratory pricing locality.

The carrier and intermediary record layouts, plus the State pricing locations are as follows:

CARRIER RECORD LAYOUT FOR DATA FILE

CLINICAL LABORATORY FEE SCHEDULE

Data Element Name Picture Location Comment
HCPCS Code X(05) 1-5  
Carrier Number X(05) 6-10  
Carrier Locality X(02) 11-12

00--Single State Carrier

01--North Dakota

02--South Dakota

20--Puerto Rico
60% Local Fee 9(05)V99 13-19  
62% Local Fee 9(05)V99 20-26  
60% Natl Limit Amt 9(05)V99 27-33  
62% Natl Limit Amt 9(05)V99 34-40  
60% Pricing Amt 9(05)V99 41-47  
62% Pricing Amt 9(05)V99 48-54  
Gap-Fill Indicator X(01) 55-55

0--No Gap-fill Required

1--Carrier Gap-fill

2--Special Instructions Apply
Modifier X(02)   56-57 Where modifier is shown QW denotes a CLIA waiver Test.
State Locality X(02) 58-59 See attached
FILLER X(01) 60  

INTERMEDIARY RECORD LAYOUT FOR DATA FILE

CLINICAL LABORATORY FEE SCHEDULE

Data Element Name Picture Location Comment
HCPCS X(05) 1-5  
Filler X(04) 6-9  
60% Pricing Amt 9(05)V99 10-16  
62% Pricing Amt 9(05)V99 17-23  
Filler X(07) 24-30  
Carrier Number X(05) 31-35  
Carrier Locality X(02) 36-37

00--Single State Carrier

01--North Dakota

02--South Dakota

20--Puerto Rico
State Locality X(02) 38-39 See Attached
FILLER X(21) 40-60  

CarrierLocality/StateLocality Map

Carrier/Loc 0051000=StateLoc 01 (ALABAMA)

Carrier/Loc 0051100=StateLoc 02 (GEORGIA)

Carrier/Loc 0051200=StateLoc 03 (MISSISSIPPI)

Carrier/Loc 0052000=StateLoc 04 (ARKANSAS)

Carrier/Loc 0052100=StateLoc 05 (NEW MEXICO)

Carrier/Loc 0052200=StateLoc 06 (OKLAHOMA)

Carrier/Loc 0052300=StateLoc 07 (MISSOURI GENERAL AMERICAN)

Carrier/Loc 0052800=StateLoc 08 (LOUISIANA)

Carrier/Loc 0059000=StateLoc 09 (FLORIDA)

Carrier/Loc 0059100=StateLoc 10 (CONNECTICUT)

Carrier/Loc 0063000=StateLoc 11 (INDIANA)

Carrier/Loc 0065000=StateLoc 12 (KANSAS)

Carrier/Loc 0065500=StateLoc 13 (NEBRASKA)

Carrier/Loc 0066000=StateLoc 14 (KENTUCKY)

Carrier/Loc 0074000=StateLoc 15 (MISSOURI)

Carrier/Loc 0075100=StateLoc 16 (MONTANA)

Carrier/Loc 0080100=StateLoc 17(WESTERN NEW YORK)

Carrier/Loc 0080300=StateLoc 18 (EMPIRE NEW YORK)

Carrier/Loc 0080500=StateLoc 19 (NEW JERSEY)

Carrier/Loc 0082001=StateLoc 20 (NORTH DAKOTA)

Carrier/Loc 0082002=StateLoc 21(SOUTH DAKOTA)

Carrier/Loc 0082400=StateLoc 22 (COLORADO)

Carrier/Loc 0082500=StateLoc 23 (WYOMING)

Carrier/Loc 0082600=StateLoc 24 (IOWA)

Carrier/Loc 0083100=StateLoc 25 (ALASKA)

Carrier/Loc 0083200=StateLoc 26 (ARIZONA)

Carrier/Loc 0083300=StateLoc 27 (HAWAII)

Carrier/Loc 0083400=StateLoc 28 (NEVADA)

Carrier/Loc 0083500=StateLoc 29 (OREGON)

Carrier/Loc 0083600=StateLoc 30 (WASHINGTON STATE)

Carrier/Loc 0086500=StateLoc 31 (PENNSYLVANIA)

Carrier/Loc 0087000=StateLoc 32 (RHODE ISLAND)

Carrier/Loc 0088000=StateLoc 33 (SOUTH CAROLINA)

Carrier/Loc 0088300=StateLoc 34 (OHIO)

Carrier/Loc 0088400=StateLoc 35 (WEST VIRGINIA)

Carrier/Loc 0090000=StateLoc 36 (TEXAS)

Carrier/Loc 0090100=StateLoc 37 (MARYLAND)

Carrier/Loc 0090200=StateLoc 38 (DELAWARE)

Carrier/Loc 0090300=StateLoc 39 (DISTRICT OF COLUMBIA)

Carrier/Loc 0090400=StateLoc 40 (VIRGINIA)

Carrier/Loc 0091000=StateLoc 41 (UTAH)

Carrier/Loc 0095100=StateLoc 42 (WISCONSIN)

Carrier/Loc 0095200=StateLoc 43 (ILLINOIS)

Carrier/Loc 0095300=StateLoc 44 (MICHIGAN)

Carrier/Loc 0095400=StateLoc 45 (MINNESOTA)

Carrier/Loc 0097320=StateLoc 46 (PUERTO RICO)

Carrier/Loc 0513000=StateLoc 47 (IDAHO)

Carrier/Loc 0544000=StateLoc 48 (TENNESSEE)

Carrier/Loc 0553500=StateLoc 49 (NORTH CAROLINA)

Carrier/Loc 1433000=StateLoc 50 (NEW YORK GHI)

Carrier/Loc 3114000=StateLoc 51 (NORTHERN CALIFORNIA)

Carrier/Loc 3114200=StateLoc 52 (MAINE)

Carrier/Loc 3114300=StateLoc 53 (MASSACHUSETTS)

Carrier/Loc 3114400=StateLoc 54 (NEW HAMPSHIRE)

Carrier/Loc 3114500=StateLoc 55 (VERMONT)

Carrier/Loc 3114600=StateLoc 56 (SOUTHERN CALIFORNIA OCCIDENTAL)

References:

Carrier Claims Processing - Reporting of Pricing Localities for Clinical Laboratory Services (Rev. 85, 02-06-04). (2015, July 10). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/carrier-claims-processing-reporting-of-pricing-localities-for-clinical-laboratory-services-rev-85-02-06-04-27192.html

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