Services are covered when appropriately documented, coded, and, where applicable, authorized per medical policy #91540. Claims lacking required documentation will be denied.
Documentation: Ordering practitioner documentation must support the tests ordered, be in the member's medical record, indicate reasons each test is indicated, and specify how results will impact clinical care.
Documentation: Lab requisition must be a signed, valid requisition from the ordering provider that specifically outlines the tests being ordered and include the specific lab, member information, ordering provider full name/credentials and NPI, facility/location where specimen was collected, sample type, date/time collected, individual who collected the sample, and date/time received at the lab.
Documentation: Final lab reports must include complete details for the entity performing the lab service (name, address, CLIA), patient full name and date of birth, ordering provider full name and NPI, facility name if different, date sample collected, date sample received at facility, and date results were reported.
Documentation: Claims must include detail of complete test results for each test performed; claims with insufficient documentation to support lab services will be denied.
Billing: When reporting an unlisted CPT code, include the specific laboratory test name and/or a short descriptor in field 19 of the claim; DEX Z‑Codes may be reported where applicable.
Billing: All molecular diagnostic tests require a unique test identifier as additional claim documentation.
Billing: Do not report Tier 1 (81105-81383) or Tier 2 (81400-81408) molecular pathology procedure CPT codes alongside a genomic sequencing procedure, molecular multianalyte assay, MAAA, or PLA CPT code if the CPT descriptor includes testing for the same analyte; separate payments for multiple methods testing the same analyte are not permitted.
Billing: Providers should not report more than one unit of service for any Tier 1 CPT code or for each listed Tier 2 procedure when testing a specimen from a single source; report one unit for a genomic sequencing procedure evaluating multiple genes.
Billing: Custom panel tests should not be referenced on the written lab order; only panel tests defined by CMS or CPT are acceptable.
Billing: Standing orders and routine screenings are not payable without documentation supporting the member's specific medical assessment and treatment.
Coding and modifiers: Use industry-standard CPT/HCPCS/revenue codes that reflect services performed and documented to the highest specificity; improper modifier application may result in denials. Priority Health follows standard billing and coding guidelines including CMS NCCI for modifier application.
Coverage notes: CPT 96041 (medical genetics and genetic counseling services, each 30 minutes) is reimbursed only when provided by trained genetic counselors; if counseling is provided by a physician or other qualified professional, the appropriate E&M code must be used.
Coverage notes: Priority Health may recover payments or deny claims if state, federal, or contract requirements are not followed; Medicare and Medicaid follow CMS and MDHHS respectively unless otherwise stated. Refer to medical policy #91540 (Appendix A) for conditions requiring genetic counseling prior to and after testing.