Laboratory claims editing for Blue Cross commercial and Medicare Plus Blue coming later this year

Starting in June 2022, Blue Cross Blue Shield of Michigan will be implementing a laboratory benefits management program, supported by Avalon Healthcare Solutions, for our Blue Cross commercial and Medicare Plus Blue℠ claims. Avalon is an independent company that contracts with Blue Cross Blue Shield of Michigan to provide laboratory benefits management.
 
This program is part of our ongoing efforts to promote correct coding and assist with payment accuracy for claims. It will help ensure appropriate testing, which helps drive quality and cost-effective medical care.

Avalon will provide routine testing management services for consistent enforcement of laboratory policies. Its services include an automated review of high-volume, low-cost laboratory tests.

Avalon’s automated policy enforcement (post-service) 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 room, hospital observation and hospital inpatient settings are excluded from this program.

This automated policy enforcement combines clinical science-based research with cutting-edge technology. Lab services reported on claims will be reviewed for adherence and consistency with our policies and guidelines, as well as industry standardized rules, such as evaluating services considered experimental or investigational, and meeting clinical appropriateness for patient demographics.

Additionally, codes reporting multiple units billed will be reviewed for appropriateness to code-specific unit allowances under our laboratory policies and guidelines. 

The program includes important changes affecting providers, such as new and revised medical policies and guidelines, and consistent reviews for certain laboratory services. The policies and guidelines will be posted online and available for providers to review prior to the program’s effective date. Providers will receive notification once policies are published, with information on where they can be found and additional program details.

We’ll announce provider education resources about this program in future communications.

Note: The appeal process won’t change. Continue to submit appeals on the Clinical Editing Appeal Form with the necessary supporting documentation. Fax one appeal at a time to avoid processing delays.