Coverage

Clinical Laboratory Partners agrees to accept the Medicare-allowed amount as payment in full for covered services. Assignment does not preclude billing the patient for services denied by Medicare. The following situations may result in a bill to the patient.

1. Non-covered Services.
   These services "include tests, visits, and procedures that are not reasonable or necessary by accepted medical standards, i.e. the services are found to be inappropriate or in excess of those required for diagnosis or treatment of the enrollee's condition" (HCFA 3045.IG) e.g., routine testing and Pap smears. CMS has determined that it is the physicians responsibility to inform patients in writing if a service may not be covered. The Medicare program does not cover tests which require but do not have FDA approval. These procedures are referred to as "Investigational Use Only" and "Research Use Only" procedures and will be billed to the patient.
2. Medical Review Policies or National Coverage Determinations.
   Test/service covered under carrier or national policies and identified as not medically necessary prior to treatment and the beneficiary has signed and Clinical Laboratory Partners has on file an "Advanced Beneficiary Notice".
3. Over-Utilization.
   CMS allows each carrier to develop utilization guidelines to monitor the frequent use of certain commonly performed procedures (e.g., CEA and automated testing).
4. Secondary Payor.
   In the following instances, Medicare is not considered the primary payor:
   1. Full-time employees and their spouses between the ages of 65-69 who have elected primary coverage under their employee group health plan.
   2. Illness or injury that could be expected to be covered under any general liability, no fault, or auto liability policies.
   3. Individuals who are entitled to Medicare solely on the basis of End-Stage Renal Disease (ESRD) and are covered under an employee group health plan.
   4. Services related to a black lung condition.
   5. Services covered by the Veteran Administration, Public Health Service, or any other federal agency.
5. Ineligible on date of service.
6. No Medicare Part B coverage.
7. The Deficit Reduction Act of 1984 mandates that either the performing laboratory or the referring laboratory bill Medicare directly for clinical laboratory services. Under this legislation, clinical diagnostic laboratory tests are reimbursed on the basis of a fee schedule. These tests include codes 80048 - 89399 listed in the CPT manual. The legislation, however, exempts the following procedures from the fee schedule:

Medicare continues to reimburse these procedures at 80% of the fee schedule amount and requires that the patient be billed for the remaining 20% coinsurance and any deductible amounts.

In order to comply with the current regulatory requirements, the following information must be provided if Clinical Laboratory Partners is to bill Medicare directly: