Drug Testing
This policy governs coverage, documentation, coding, limits, and reimbursement for presumptive and definitive drug testing for Priority Health members across commercial, Medicare (per CMS), and Medicaid (per MDHHS). It affects ordering providers and billing laboratories submitting claims to Priority Health.
Added 'Disclaimer' section.
Added language regarding proprietary testing not covered.
Change to testing limits.
Coverage and Medical Necessity Criteria
Medical necessity and coverage criteria
Covered when ALL of the following are met:
See Documentation requirements; standing orders or unspecified custom panels are not acceptable.
Presumptive results should be reviewed by the ordering/treating provider before ordering definitive testing.
Ordering provider must document rationale in the medical record; see coding descriptions for method requirements (e.g., LC/MS, GC/MS, stable isotope/internal standards, method- or drug-specific calibration and matrix-matched QC).
Use listed CPT/HCPCS codes only; proprietary methodologies are excluded.
Third-party codes and proprietary testing codes are not reimbursable and may be denied when billed to Priority Health. Reimbursement will be considered only for the listed presumptive and definitive CPT/HCPCS codes; use of third-party or proprietary methodology codes is excluded from coverage.
The requisition must include a legible signature from the ordering provider. A photocopy, stamp, or “signature on file” is not accepted as a valid signature and will not meet the requisition signature requirement.
Definitive testing codes (e.g., G0480-G0483, G0659 and CPT 80320-80377/83992) should not be performed routinely and are not appropriate for every specimen. The ordering provider must document the medical necessity and rationale for each definitive test in the medical record (for example, inconsistent presumptive findings or inability to perform a presumptive test for a specific drug), and review of presumptive results by the ordering/treating provider should occur prior to ordering definitive testing.
Codes, Billing Limits, and Frequency
| 80305 | Presumptive drug testing, any number of drug classes, any number of devices or procedures (e.g., immunoassay); capable of being read by direct optical observation only; includes sample validation when performed, per date of service. |
| 80306 | Presumptive drug testing, any number of drug classes, any number of devices or procedures; read by instrument-assisted direct optical observation; includes sample validation when performed, per date of service. |
| 80307 | Presumptive drug testing by instrument chemistry analyzers or chromatography/mass spectrometry methods; includes sample validation when performed, per date of service. |
| G0480 | Definitive drug testing, qualitative or quantitative, 1-7 drug classes, includes specimen validity testing, per day. |
| G0481 | Definitive drug testing, qualitative or quantitative, 8-14 drug classes, includes specimen validity testing, per day. |
| G0482 | Definitive drug testing, qualitative or quantitative, 15-21 drug classes, includes specimen validity testing, per day. |
| G0483 | Definitive drug testing, qualitative or quantitative, 22 or more drug classes, includes specimen validity testing, per day. |
| G0659 | Definitive drug testing performed without method- or drug-specific calibration/matrix-matched QC or without stable isotope internal standards; qualitative or quantitative, any number of drug classes, includes specimen validity testing, per day. |
| 80320-80377 | Validity and definitive testing CPT codes for specific drug/drug class panels (detailed individual codes listed in policy). |
| 83992 | Phencyclidine (PCP) testing (listed among validity/definitive codes). |
Provider Responsibilities and Billing Risks
Prior Authorization Required for Out-of-Network Labs
HMO/EPO plans require prior authorization for all out-of-network (OON) laboratory testing. POS and PPO plans do not require prior authorization for OON labs, but OON labs will be processed at the member's out-of-network benefit level.
Denial Risk — Insufficient Documentation
Claims submitted without adequate clinical and administrative documentation to support the testing performed will be denied. Failure to document services rendered or to provide requested supporting records (including the lab order, requisition and results) will result in claim denial and potential denial of all services reported.
- If requested, medical records must be produced by the ordering provider to support medical necessity and coding.
- Submitting orders or requested information alone does not guarantee reimbursement; both lab and ordering provider documentation must meet policy requirements.
Denial Risk — Proprietary / Third-Party Tests Not Reimbursable
Third party codes and proprietary testing codes are not reimbursable and may be denied. Proprietary methodologies or unique company-owned test codes should not be billed to Priority Health.
- Do not submit third-party or proprietary test codes; use industry-standard CPT/HCPCS codes only.
- If a proprietary test maps to standard CPT/HCPCS codes, documentation must clearly justify medical necessity and the mapping.
Documentation and Final Report Requirements
The ordering practitioner's documentation and the final laboratory report must fully support each test ordered. Each drug or drug class ordered should be documented in the member's medical record and detailed on the lab order, with the clinical rationale for testing and how results will impact patient management.
- Orders must list each specific drug or drug class being tested and the clinical reason for each test.
- Standing orders, custom panels, or routine protocol screenings are not acceptable without member-specific documentation.
- Final lab reports must include complete test results and the performing entity's details (name, address, CLIA).
Requisition Minimum Data
Requisition minimum data requirements: the requisition must be a signed, valid order from the ordering provider that specifically outlines the tests being ordered and the specific drugs/drug classes. It must include member information, ordering provider full name and credentials, ordering provider NPI, and a legible provider signature (photocopy/stamp/signature on file not accepted). Additionally, the requisition must document collection details including facility/location where specimen was collected, sample type, date and time sample collected, individual who collected the sample, and date/time received at the laboratory.
- Signed, valid requisition — tests and specific drugs/drug classes clearly listed.
- Ordering provider full name, credentials, and NPI; legible original signature required.
- Specimen collection details: facility/location, sample type, date/time collected, collector identifier, and date/time received at lab.
When Testing Is Covered
Testing to support management of a member's specific medical condition when documented by ordering provider.
Covered when the ordering provider documents how testing supports management of the member's specific medical condition:
Specific drugs or drug classes must be clearly detailed; standing orders or custom panels should not be used on the written lab order.
Labs should retain and provide the lab order, requisition and results if medical records are requested.
Definitive testing requires documentation of why it is necessary in place of or following presumptive testing.
Testing Frequency and Limits
Order Signatures, Content, and Prior Auth
Orders must be signed, dated, and list specific drugs/drug classes
Orders must be signed and dated by the ordering practitioner and include each specific drug or drug class being tested; standing orders or references to custom/standing panels are not acceptable without member‑specific documentation.
- Specific drugs or drug classes should be clearly detailed on the written lab order.
- Do not rely on standing orders, standard protocols, or custom panels without documentation demonstrating medical necessity for the individual member.
Plan‑specific prior authorization rules for OON labs
For HMO and EPO members, obtain prior authorization for all out‑of‑network laboratories; POS and PPO claims for OON labs will be processed at the out‑of‑network benefit level (no prior authorization required).
Not Covered Services
Third-party and proprietary testing codes are excluded from reimbursement. Priority Health will consider reimbursement only for the specific presumptive and definitive CPT/HCPCS codes listed in the policy; claims billed with proprietary or third-party codes may be denied.
Key Definitions
Background and Rationale
Presumptive (qualitative) testing determines the presence or absence of a substance within a general drug class and yields non‑numeric (positive/negative) results. Definitive testing identifies specific drugs or concentrations and yields numeric results; definitive methods use techniques such as GC/MS or LC/MS and require documentation of rationale and medical necessity before performance. Review of presumptive results by the ordering provider should occur prior to ordering definitive testing, and the rationale for definitive testing must be documented in the medical record.
Policy Changes and Revision History
Updated annual billing limit for qualitative and/or quantitative drug tests.
Added language clarifying that proprietary and third‑party testing codes are not reimbursable.
Added 'Disclaimer' section to the policy document.
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.