ModifiedEmblemHealthPolicy N/A

Laboratory Benefit Management (LBM) Program and Routine Testing Management

Defines EmblemHealth and ConnectiCare's Laboratory Benefit Management program implemented with Avalon Healthcare Solutions to review and apply automated rules to outpatient laboratory claims for adherence to payer lab reimbursement policies; affects providers submitting outpatient lab claims to EmblemHealth/ConnectiCare.

Policy Summary

PayerEmblemHealth

PolicyLaboratory Benefit Management (LBM) Program and Routine Testing Management

Policy CodePolicy N/A

Change TypeAdded examples and clarified table of contents

Effective DateN/A

Next Review DateN/A

Key ActionProviders should review the linked LBM reimbursement policy resources and adjust claims or submit corrected claims when automated edits indicate unit or frequency limits have been exceeded.

SourceLink

POLICY UPDATE CHANGES

Added Examples of Claim Decision Responses with Descriptions and additional examples for clarity.

'Sample Policy Summary' title updated to 'Sample Policy Overview Example'.

Added 'Sample Policy Overview Example', 'Examples of Avalon Policy Enforcement Application', and 'Examples of Claim Decision Responses' to the Table of Contents.

>70routine outpatient lab policies maintained by Avalon's science team

13 billionlab tests performed in the US each year (context/statistic cited)

40/yrexample unit limit for code 86003 (Allergen specific IgE)

example claim exceeding allowed units

10/2024most recent revision date listed

Automated Enforcement & Example Criteria

APEA Enforcement Criteria Examples

Automated rules (APEA) enforce fixed coverage criteria from EmblemHealth/ConnectiCare policies and industry coding guidelines for outpatient lab claims; examples and rule types follow.

APEA applies to all outpatient lab testing and enforces fixed coverage criteria per EmblemHealth/ConnectiCare policies and industry coding guidelines (AMA CPT/HCPCS, ICD-10, and other lab coding guidance).

APEA edits are applied post-service and pre-payment; ER/Inpatient/Observation claims are out of scope.

ALL of the following

ONE OF
- Diagnosis compatibility: Procedure and diagnosis code must be compatible; some procedures may be always allowed or never allowed depending on diagnosis.
- Demographic constraints: Age-based restrictions may make procedures ineligible for certain age ranges.
- Frequency / Units per period: Maximum allowable units within a defined period of time (e.g., unit limits per year or per months).
- Procedure units limit: Limits on units within and across a claim for a date of service.
- Time between procedures: Minimum time interval required before repeating a procedure.
- Mutually exclusive procedures: Procedures that cannot be billed together in the same day/setting.

Appeals and remittance: Appeals continue to be handled by EmblemHealth and ConnectiCare; denial reason communicated on EOP/EOB and Provider 835 Remittance advice.

Illustrative coverage criteria and edit rules

Illustrative examples of policy edits and unit thresholds (for full, current criteria see the linked full policies).

EXAMPLES OF DIAGNOSIS/PROCEDURE EDITS

Vitamin D: Procedure and diagnosis compatibility; can be flagged as Always allowed or Never allowed.
Vitamin B12: Procedure and diagnosis compatibility; can be flagged as Always allowed or Never allowed.
HbA1c: Procedure and diagnosis compatibility with rules that vary by diabetic status and age (e.g., diabetic or pregnant; not diabetic for >=18-year-old; not diabetic for <18-year-old).
Cervical Cancer Screening: Procedure and diagnosis compatibility with demographic (age) rules and units/period-of-time constraints.

ALL of the following

Coding, Frequency Limits, and Unit-Limited Codes

APEA automated coding enforcementmixedCovered

APEA edits apply post-service and pre-payment to outpatient lab testing per AMA CPT/HCPCS and ICD-10 coding guidelines and other lab coding guidance.

APEA source referencemixed

APEA applies to all outpatient lab testing; ER/Inpatient/Observation claims out of scope; enforces 'fixed' coverage criteria from EmblemHealth and ConnectiCare policy.

Covered CPT Codes (unit-limited)CPTCovered

86003

Allergen specific IgE; quantitative or semiquantitative, crude allergen extract, each (limited to 40 units per year)

Example frequency limits — common tests

Vitamin D frequencyTwo units per year

Vitamin B12 frequencyOne unit every three months

HbA1c frequencyOne unit every three months

Annual unit limit for 86003

86003 annual unit limit40 units per year

Provider Notices, Appeals, and Claim Response Guidance

Note

Provider notification prior to enforcement

Provider notice period prior to enforcement.

Denial Risk

Appeals and remittance communications

Appeals continue to be handled by EmblemHealth and ConnectiCare; denials and the denial reason are communicated on the member EOP/EOB and on the provider 835 remittance advice.

Program Definitions and Edit Types

LBM Program — definition

Program partnersEmblemHealth and ConnectiCare collaborate with Avalon Healthcare Solutions to implement an LBM program

ScopeAutomated review of outpatient laboratory services (post-service and pre-payment) across office, hospital outpatient, and independent laboratory settings; ER/Inpatient/Observation out of scope

PurposeSupport appropriate laboratory science, reduce overutilization, and promote consistent routine testing per payer policies

ToolingAvalon proprietary software (APEA) performs automated edits to ensure compliance with reimbursement policies

APEA / Policy edit types — enforcement examples

Diagnosis-Procedure compatibility

Policy Summary

PayerEmblemHealth

PolicyLaboratory Benefit Management (LBM) Program and Routine Testing Management

Policy CodePolicy N/A

Change TypeAdded examples and clarified table of contents

Effective DateN/A

Next Review DateN/A

Key ActionProviders should review the linked LBM reimbursement policy resources and adjust claims or submit corrected claims when automated edits indicate unit or frequency limits have been exceeded.

SourceLink

On This Page

SAMPLE LIMITS

Vitamin D: Two units per year.
Vitamin B12: One unit every three months.
HbA1c: One unit every three months.

ALL of the following

Code 86003 (Allergen specific IgE; quantitative or semiquantitative, crude allergen extract, each) — policy limits units for this code to 40 per year.
IF EXCEEDED: Claims that exceed the maximum allowable units within a defined time period will be denied; submit a corrected claim with allowable units.
Illustrative claim scenario: Billed units 45 on one claim, another DOS billed 32 units, member history shows 10 units previously approved — combined they exceed the annual 40-unit allowance and would trigger denial or adjustment.

Operational note: Refer to the full policy for coverage criteria and unit allowances and submit corrected claims to reflect allowable units when required.

Claims adjustments/denials and LBM policy reference

Claims may be adjusted or denied with the Laboratory Benefit Management (LBM) Reimbursement Policy applied; providers are directed to the LBM policy link (bit.ly/Our-RP) to view the applicable test policy and rationale for adjustments or denials.

Typical denial/adjustment reasons include: diagnosis inconsistent with the procedure and units or days of service exceeding acceptable maximums.
Remittance reason codes shown (e.g., GAT/GAS/GBO/GB4) indicate LBM Reimbursement Policy application and may show adjustment code 151 when payment is reduced for unsupported frequency/units.

Edits ensure procedure and diagnosis codes are compatible; some procedures marked always allowed or never allowed

Demographic (age) constraintsAge-based limitations may make procedures ineligible for certain age ranges

Units per periodLimits maximum allowable units within a defined time period (e.g., units/year or units per 3 months)

Time-between proceduresMinimum time interval required before repeating a procedure

Laboratory Benefit Management (LBM) — expanded definition

DefinitionLaboratory Benefit Management (LBM) program: collaboration with Avalon to implement automated review of outpatient lab claims for adherence to payer lab policies

ObjectivesEnsure right test ordered using evidence-based policies; improve patient quality, access, and affordability of lab care

Operational approachUses Avalon’s APEA software for routine testing management with automated, high-volume reviews applied post-service and pre-payment

ExclusionsNot utilization management/medical necessity; ER/Inpatient/Observation claims excluded