New lab program for Blue Cross commercial and Medicare Plus Blue now live

As previously communicated in the March, June and July issues of The Record, Blue Cross Blue Shield of Michigan has instituted a laboratory benefits management program supported by Avalon Healthcare Solutions, an independent company. This program uses enhanced editing to promote correct coding and assist with accurate claim payment.

While the program’s original implementation date was delayed, you may have started receiving edits for laboratory services received in August for dates of service on or after June 1, 2022.

Place of service exclusion

Outpatient Blue Cross commercial and Medicare Plus Blue℠ claims won’t be subject to laboratory editing until further notice.

What you need to know about appeals

Should an edit occur on a claim, Blue Cross will continue to allow for an appeal submission using availity.com** or the Clinical Editing Appeal Form through fax or mail. Before you submit an appeal, we encourage you to review the Routine Laboratory Testing Policies, clinical documentation and claim information to determine whether a reconsideration or appeal is needed.

Reconsideration can be used when updating ICD-10 codes and modifiers. To access the Blue Cross Blue Shield of Michigan Routine Laboratory Testing Policies, click here.

If there are no updates to be made using a corrected claim for reconsideration, an appeal can be submitted when review of the clinical documentation will support payment using the policy criteria of the denied code.

When submitting an appeal

Include the clinical documentation to support the laboratory test. An appeal received with only the lab order and results won’t contain the necessary information for a proper review. Clinical documentation from the ordering health care provider is necessary and should be included with the appeal. Blue Cross won’t contact the ordering provider for this information. 

New tool

The Trial Claim Advice Tool can assist providers by inputting codes for services, along with patients’ diagnoses, to determine possible edits in advance of submitting a new claim or reconsideration. To access the tool, follow these steps:

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

Note: Medicare NCDs and LCDs will supersede Avalon policies when applicable.

On-demand training available

To learn more about the program, view the Avalon Laboratory Services Overview under Claims or by entering Avalon in the search box on our provider training website. To request access to the provider training site, complete the following steps:

1. Open the registration page.
2. Complete the registration. We recommend using the same email you use to communicate with Blue Cross for other provider-related needs. This will become your login ID.
3. Follow this link to log in.

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