Lab Reimbursement Policy
Dear Valued Provider,
MetroPlusHealth is committed to keeping our provider network informed of important policies. This notice serves as a reminder of MetroPlusHealth’s lab reimbursement policy.
Impacted Plans:
Medicaid, HIV SNP, HARP, QHP, Gold, Goldcare, Essential Plans (EP), Child Health Plus, Medicare and UltraCare.
Laboratory Claims Billing and Reimbursement Criteria may vary by Product For Medicaid, HIV SNP, HARP, Gold, Goldcare, EP, and Child Health Plus:
- MetroPlusHealth reimburses lab services when billed with specific procedure codes found in the published NYS Medicaid Lab Fee Schedule posted at: https://www.emedny.org/providermanuals/laboratory/
- Prior authorization rules may apply.
- Claims billed with procedure codes not listed in the NYS Medicaid Fee schedule are subject to denial with the Explanation of Payment (EOP) reason: “Lab is not covered.”
For Medicare, UltraCare, and QHP:
- MetroPlusHealth reimburses lab services for specific procedure codes found in the published CMS Lab Fee Schedule.
- Prior authorization rules may apply.
- Claims billed with procedure codes not listed in the CMS Fee Schedule are subject to denial with the EOP reason: “Lab is not covered.”
Billing Reminder:
- Lab providers should not bill for lab services with unspecified codes when a specific code is available. Claims with unspecified codes are subject to denial with EOP reason: “Do Not Pay, submit specific code or appeal Plan denial”.
- Providers should call MetroPlus Health if in certain rare instances they need to utilize the unspecified code in billing.
- If a Lab receives a test order with an unspecified code from the referring physician, please contact the referring provider to determine the correct procedure code.
Below is a sample set of unspecific or unlisted codes listed as “By Report” (BR) in the NYS Medicaid fee lab schedule that may result in a denial with an EOP “Do Not Pay, submit specific code or appeal Plan denial”.
| (15) Codes | Code Description |
|---|---|
| 81408 | MOLECULAR PATHOLOGY PROCEDURE, LEVEL 9 |
| 81599 | UNLISTED MULTIANALYTE ASSAY WITH ALGORITH |
| 84591 | VITAMIN, NOT OTHERWISE SPECIFIED |
| 84999 | UNLISTED CHEMISTRY PROCEDURE |
| 86256 | FLUORESCENT NONINFECTIOUS AGENT ANTIBODY |
| 86609 | ANTIBODY; BACTERIUM, NOT ELSEWHERE SPECIFIED |
| 86671 | ANTIBODY; FUNGUS, NOT ELSEWHERE SPECIFIED |
| 86682 | ANTIBODY; HELMINTH, NOT ELSEWHERE SPECIFIED |
| 86753 | ANTIBODY; PROTOZOA, NOT ELSEWHERE SPECIFIED |
| 86790 | ANTIBODY; VIRUS, NOT ELSEWHERE SPECIFIED |
| 86849 | UNLISTED IMMUNOLOGY PROCEDURE |
| 87299 | DETECTION TEST BY IMMUNOFLUORESCENT TECHNIQUE FOR ORGANISM |
| 87797 | DETECTION TEST BY NUCLEIC ACID FOR ORGANISM, DIRECT PROBE TECHNIQUE |
| 87798 | DETECTION TEST BY NUCLEIC ACID FOR ORGANISM, AMPLIFIED PROBE TECHNIQUE |
| 87801 | INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), MULTIPLE ORGANISMS; AMPLIFIED PROBE(S) TECHNIQUE |
Lab Providers should not utilize unlisted codes on the Laboratory Fee Schedule to submit claims that have been assigned a specific code.
If you have any questions or need assistance, please contact MetroPlusHealth Provider Services at 866.986.0356.
Thank you for your continued collaboration.
MetroPlusHealth