Independent Lab Reimbursement Changes Effective Aug. 1, 2022
Effective Aug. 1, 2022, independent laboratories shall bill services to the hospital for whom they are providing clinical lab services.
- The hospital shall then bill the services, including any independent laboratory services, to the prepaid health plans (PHPs).
- It is the expectation that PHPs reimburse the hospital for the clinical laboratory services billed and not the clinical laboratory.
This process change follows an internal review of our State Plan Authority related to the Independent Lab reimbursement methodology (Attachment 4.19-B, Section 3). NC Medicaid has determined that Independent Lab reimbursement for services provided on behalf of a hospital and our State Plan reimbursement methodology do not align with respect to the adjudication of Independent Lab claims.
As stated in Attachment 4.19-B, section 3, of the State Plan Amendment, when clinical laboratories services are provided on behalf of a hospital inpatient or critical access hospital inpatient, payment will be made to the hospital and not to the clinical laboratory.
Previous guidance remains in effect for claims with date of service beginning July 1, 2021. PHPs shall continue to reimburse all Hospital Outpatient Laboratory providers under NC Medicaid Managed Care based on the PHP Managed Care Hospital Outpatient Laboratory Fee schedule provided by NC Medicaid.
The Department is conducting internal discussions to determine whether additional actions may be necessary regarding this reimbursement policy. However, PHPs shall follow the independent lab reimbursement methodology as currently outlined in the State Plan.
NC Medicaid Contact Center, 888-245-0179