CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medicare Advantage Plans Laboratory Network Hospital Outpatient Allowable Test Listing

Defines which outpatient laboratory CPT/HCPCS codes are allowed to be performed in Hospital CLIA-certified labs outside BCBSRI's limited outpatient laboratory network for Medicare Advantage members; excludes ER/observation tests and does not itself determine medical necessity or reimbursement.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedicare Advantage Plans Laboratory Network Hospital Outpatient Allowable Test Listing

Policy CodePolicy N/A

Change TypeNo material change

Effective Date06|01|2021

Next Review DateN/A

Key ActionRefer to the applicable policy for any prior authorization requirements; appearance on this list does not imply coverage—check Evidence of Coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4specific hospitals listed as restricted for outpatient lab reimbursement

multipleCPT/HCPCS and U-codes listed as allowable for those hospitals

06/01/2021network restriction effective date

11|05|2025policy last reviewed

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.

Coverage guidance and limitations

Appearance on this allowable list does not guarantee coverage; benefits vary by plan and medical necessity rules apply.

The outpatient laboratory services listed are the only outpatient laboratory services reimbursed to the specific hospital outpatient facilities named in this policy (Landmark Medical Center; Sturdy Memorial Hospital; Southcoast Hospitals [St. Luke's, Charlton]; Westerly Hospital).

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

This policy documents which codes are allowed to be performed in hospital CLIA-certified labs outside of the approved outpatient laboratory network; it does not itself determine medical necessity or reimbursement. Refer to the applicable clinical coverage policies for medical necessity determinations and separate reimbursement rules.

Provider liability and restrictions

All laboratory codes submitted that are outside of the Allowable Medicare Advantage Hospital Outpatient Laboratory Services list will deny for provider liability when billed by the listed hospitals.
For hospitals in the local network other than those specifically listed, there is no restriction on laboratory codes that can be rendered.

Tests obtained in the hospital emergency room or while the patient is in observation status are excluded from this policy's scope.

CPT codes for CLIA waived tests must have the QW modifier appended when billed to be recognized as waived tests.

Allowable outpatient hospital laboratory codes and coding rules

Allowable outpatient hospital laboratory codesmixedCovered

85379	Fibrin degradation products, D-dimer; quantitative
86850	Antibody screen, RBC, each serum technique
86900	Blood typing, serologic; ABO
86901	Blood typing, serologic; Rh (D)
87015	Concentration (any type), for infectious agents
87154	Culture, typing; identification of blood pathogen and resistance typing, when performed, by nucleic acid (DNA or RNA) probe, multiplexed amplified probe technique including multiplex reverse transcription, when performed, per culture or isolate, 6 or more targets
88106	Cytopathology, fluids, washings or brushings, except cervical or vaginal; simple filter method with interpretation
88112	Cytopathology, selective cellular enhancement technique with interpretation (eg, liquid based slide preparation method), except cervical or vaginal
88142	Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision
88173	Cytopathology, evaluation of fine needle aspirate; interpretation and report

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CLIA waived modifier requirement

RequirementCPT codes for CLIA waived tests must have modifier QW appended.

ApplicabilityApplies to Current Procedural Terminology (CPT) codes for CLIA tests performed in hospital outpatient settings listed in this policy.

PurposeEnsures the test is recognized as CLIA-waived when billed so it is processed appropriately by the payer.

Reference noteModifier QW must be present on claims for waived tests — absence may affect recognition of waived status.

Prior authorization and provider notice

Prior Authorization

Prior authorization and coverage notice

Refer to the applicable prior authorization policy for any authorization requirements. Appearance on this allowable list does not imply coverage; benefits may vary between individual plans, so check the member's Evidence of Coverage for applicable laboratory benefits and coverage determinations.

Scope and provider liability

Allowable outpatient hospital laboratory services (Medicare Advantage)

DefinitionOutpatient laboratory services listed are the only outpatient lab services reimbursed to the specified hospital outpatient facilities for Medicare Advantage members.

Included facilitiesLandmark Medical Center; Sturdy Memorial Hospital; Southcoast Hospitals (St. Luke's, Charlton); Westerly Hospital.

ExclusionsNot applicable to laboratory tests obtained in the hospital emergency room or observation status.

Coverage caveatAppearance on the allowable list does not imply coverage; benefits vary by plan and medical necessity rules apply — refer to Evidence of Coverage.

Provider liability for out-of-list lab codes

Provider liability statementAll laboratory codes submitted that are outside of the Allowable Medicare Advantage Hospital Outpatient Laboratory Services list will deny for provider liability.

ScopeApplies to the listed hospitals (Landmark Medical Center; Sturdy Memorial; Southcoast Hospitals; Westerly Hospital).

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

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