CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Hospital Outpatient Laboratory Services — Medicare Advantage network restriction

Defines which outpatient clinical laboratory CPT/HCPCS codes are restricted to specific hospital outpatient facilities for Medicare Advantage members of BCBSRI; applies to providers and affected members in Rhode Island.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyHospital Outpatient Laboratory Services — Medicare Advantage network restriction

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 1, 2021

Next Review DateN/A

Key ActionRefer to the applicable policy for any authorization requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

11+ codesEnumerated allowable outpatient lab codes

4 hospitalsNamed limited facilities

06/01/2021Effective date

Medicare AdvantagePlan type

Not applicableER/observation exclusion

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Hospital Outpatient Laboratory Reimbursement Limitation

Hospital outpatient laboratory reimbursement limitation

Reimbursement limitation for specified outpatient laboratory services provided in hospital outpatient settings for Medicare Advantage members:

Only the outpatient laboratory services listed in the policy are reimbursed to the following facilities for Medicare Advantage plans: Landmark Medical Center; Sturdy Memorial Hospital; Westerly Hospital; and Southcoast Hospitals (St. Luke's, Tobey, Charlton).

Effective June 1, 2021, this network restriction is no longer applicable to Physician Laboratories or Urgent Care Facilities.

For all other hospitals in the local network there is no restriction on the laboratory codes that can be rendered.

Note: CPT codes for CLIA waived tests must have the QW modifier appended to be recognized as a waived test.

Appearance on this list does not imply coverage; benefits may vary between individual plans—refer to the applicable Evidence of Coverage for laboratory benefits/coverage.

Not applicable to laboratory tests obtained in the hospital emergency room or observation status.

Policy brief indicates ED/observation are excluded from the outpatient hospital restriction.

Allowable Hospital Outpatient Laboratory CPT/HCPCS Codes

Allowable Medicare Advantage hospital outpatient laboratory CPT/HCPCS codes (selected examples)mixedCovered

85379	Fibrin degradation products, D-dimer; quantitative
86850	Antibody screen, RBC, each serum technique
86900	Blood typing, serologic; ABO
86901	Blood typing, serologic; Rh
87154	Culture, typing; identification of blood pathogen and resistance typing by nucleic acid probe, multiplexed, per culture or isolate
88106	Cytopathology, fluids, washings or brushings; simple filter method with interpretation
88300	Surgical pathology gross
86328	Immunoassay for infectious agent antibodies; SARS-CoV-2
87635	Infectious agent detection by nucleic acid; SARS-CoV-2, amplified probe technique
U0001	CDC 2019 novel coronavirus real-time RT-PCR diagnostic panel

1–10 of 11

1/2

Authorization and Billing Actions

Prior Authorization

Prior authorization note

Refer to the applicable policy for any authorization requirements.

Modifiers and Coverage Caveats

QW — CLIA waived test modifier

ModifierQW — must be appended to CPT codes for CLIA waived tests (Current Procedural Terminology codes for CLIA tests must have the modifier QW appended to be recognized as a waived test).

PurposeIdentifies tests performed as CLIA-waived so they are recognized appropriately for processing and reimbursement.

Applicable codesApplies to CPT codes listed in the policy (examples include 85379, 86850, 86900, 86901).

Scope noteApplies where tests are performed in Hospital CLIA‑certified labs outside the approved outpatient laboratory network as described in the policy.

Coverage caveat

Coverage implicationAppearance on this list does not imply coverage; benefits may vary and Evidence of Coverage should be consulted.