Laboratory claims editing coming to Blue Cross commercial and Medicare Plus Blue

As we wrote in a March 2022 Record article, starting in June 2022, Blue Cross Blue Shield of Michigan will be implementing a laboratory benefits management program, supported by Avalon Healthcare Solutions, for 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.

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.

New and revised laboratory medical policies and guidelines will take effect, which will affect certain laboratory, services, tests and procedures. To review medical policies, follow these steps:

• Go to bcbsm.com/providers.
• Click on Resources.
• Scroll down to Looking for Medical Policies.
• Click on SEARCH MEDICAL POLICIES.

Trial Claim Advice Tool
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

Keep in mind that 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.

Educational webinars

Live educational webinars will be available to provide important information on the laboratory benefits management program, including lab policy administration, routine testing management, how to locate policy information and the trial claim advice tool. The webinar will also be recorded and made available on our provider training website.

Register for one of the sessions below:

May 17 – 8 to 9 a.m. Eastern time. To register, click here.
May 19 – 1:30 to 2:30 p.m. Eastern time. To register, click here.

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.

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