This bulletin applies to NC Medicaid Direct and NC Medicaid Managed Care.
NC Medicaid is reminding providers of billing requirements for clinical laboratory services. Proper billing ensures claims are submitted by the appropriate provider and helps prevent unnecessary claim denials, recoupments and compliance concerns.
Billing Clinical Laboratory Services
Clinical laboratory services must be billed by the laboratory that performs the testing.
The ordering physician, practitioner, clinic or other healthcare provider may order laboratory testing but may not bill NC Medicaid for laboratory tests performed by an independent or reference laboratory.
Providers may bill for specimen collection services, when appropriate and separately reimbursable, but may not bill for the laboratory test itself unless they performed the testing in accordance with applicable laboratory certification requirements.
In-House Laboratory Services
Providers operating an in-house laboratory may bill for laboratory testing only when:
- The laboratory holds the appropriate Clinical Laboratory Improvement Amendments (CLIA) certification for the complexity of testing performed.
- The claim is submitted under the laboratory taxonomy associated with the performing laboratory.
Providers should review NC Medicaid's CLIA certification requirements bulletin for additional information: Reminder: Clinical Laboratory Improvement Amendments (CLIA) Certification Requirements for Drug and Other Laboratory Testing.
Hospital Inpatient Exception
An exception exists for clinical laboratory services provided on behalf of an inpatient hospital or critical access hospital.
As described in State Plan Attachment 4.19-B, payment for clinical laboratory services furnished on behalf of an inpatient hospital or critical access hospital is made to the hospital and not to the performing clinical laboratory.
Ordering Provider National Provider Identifier Requirements
NC Medicaid requires the individual ordering provider National Provider Identifier (NPI) on drug testing claims.
Providers should review the following bulletin for additional information related to drug testing laboratory services: Individual Ordering Provider NPI Must Be Included on Drug Testing Claims.
Providers should also review the following bulletin for additional information related to Federal Regulation Guidelines for Ordering, Prescribing or Referring (OPR) Providers: Federal Regulation Guidelines for Ordering, Prescribing or Referring (OPR) Providers | NC Medicaid
Key Reminders
- The performing laboratory bills the laboratory procedure code.
- Ordering providers may not bill for laboratory tests performed by another laboratory.
- Ordering providers may bill specimen collection services, when applicable.
- In-house laboratory testing must be performed under appropriate CLIA certification requirements and billed under the laboratory taxonomy of the performing laboratory.
- Inpatient hospital or critical access hospital laboratory services are reimbursed to the hospital.
- The individual ordering provider NPI is required.
Contact
NCTracks 800-688-6696