Here’s what you need to know about Prepayment Laboratory Claim Edits and how to provide input

Blue Cross Blue Shield of Michigan is proposing fourth-quarter implementation of a laboratory benefits management program through Avalon Healthcare Solutions. This program will affect independent and facility outpatient lab services for our commercial Blue Cross members.

Avalon is an independent company that contracts with Blue Cross to provide laboratory benefits management.

Avalon’s automated policy enforcement (post-service) edits will be applied to claims reporting laboratory services performed in office, hospital outpatient and independent laboratory locations. Laboratory services, tests and procedures provided in emergency department, hospital observation and hospital inpatient settings are excluded from this program.

This program will:

• Promote consistency of routine testing across all patients and places of service.
• Reduce fraud, waste and abuse.
• Enhance the patient health care experience, ensuring it’s aligned with scientific evidence-based guidelines.
• Deliver value-driven care by improving quality and appropriateness of lab services.
• Increase payment accuracy as it relates to allowable provider reimbursement associated with lab claims.

What this means to facilities

The lab claim edits will support our medical policy in cases where there’s fixed criteria, specificity and no risk of a different interpretation that would require a medical review. Edit types include:

• History
• Quantity
• Frequency
• Procedure code-diagnosis code comparison
• Incompatibility
• Age

The claim edits will focus on high-volume, low-cost tests, such as vitamin D, thyroid, cholesterol and A1c. They will identify unnecessary units (excessive units, unnecessary testing and over-frequency).

Facilities need to be aware of the new and revised laboratory medical policies and guidelines, as these polices and guidelines affect certain laboratory services, tests and procedures. Facility and independent lab reimbursement may be reduced if the lab tests ordered by the physician and provided by the labs don’t meet these policies, which became effective June 1, 2022.

To review laboratory medical policies, click on this link.** The following polices are expected to have the most significant effect on facilities:

• Prescription Medication and Illicit Drug Testing in the Outpatient Setting
• Vitamin D Testing — variance
• Vitamin B12 and Methylmalonic Acid Testing
• Cardiovascular Disease Risk Assessment
• Thyroid Disease Testing
• Testosterone Testing

Trial Claim Advice Tool

Before ordering a test, health care providers can use the Trial Claim Advice Tool to simulate a trial claim by inputting codes for services, along with patients’ diagnoses, to determine possible edits in advance of submitting claims. To access the tool, follow these steps:

• Log in to our provider portal (availity.com).**
• Click on Payer Spaces on the Availity menu bar.
• Click on the BCBSM and BCN logo.
• Click on Avalon Lab Claim Editing on the Applications tab.

This tool will review claims with laboratory services for adherence and consistency with our laboratory policies, such as:

• Meeting policy coverage criteria
• Appropriateness for patient’s age
• Frequency of services
• Whether a procedure is considered experimental or investigational
• Whether it’s appropriate for the clinical situation

Notes:

• This is a simulation tool and doesn’t guarantee approval or reimbursement of a claim.
• It’s expected that health care providers who order lab tests are doing so appropriately, according to medical necessity and relevant guidelines.
• Blue Cross and Avalon will offer health care provider education seminars prior to implementation. Ongoing support tools will also be available through provider portals.

Input requested

According to the Contract Administration Process — part of the Participating Hospital Agreement that went into effect July 1, 2021 — we allow nonbinding input from participating facilities about such proposals.

Input from facilities is requested by July 31, 2022. Send any input you may have to Liz Bowman at ebowman@bcbsm.com.

After input is received, Blue Cross has 30 calendar days to respond.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.