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24.2 Benefits, Limitations, and Authorization Requirements
Authorization is not required for laboratory services.
The CSHCN Services Program may reimburse the following laboratories for services when the laboratory is certified according to the CLIA regulations and enrolled in the CSHCN Services Program:
• A hospital laboratory for outpatient and nonpatient client claims
•A physician's office
•An independent laboratory
Providers must bill the most specific diagnosis and procedure codes that describes the services provided.
Laboratory tests generally performed as a panel and performed on the same day by the same provider, must be billed as a panel, regardless of the method used to perform the tests (automated or manual).
The CSHCN Services Program pays only the amount allowed for the total component for the same procedure, same client, same date of service, and any provider.
•Providers who perform both the technical service and interpretation must bill for the total component.
•Providers who perform only the technical service must bill for the technical component.
•Providers who perform only the interpretation must bill for the interpretation component.
Claims filed in excess of the amount allowed for the total component for the same procedure, same dates of service, same client, any provider, are denied.
Claims are paid based on the order in which they are received. For example, if a claim is received for the total component, and if payment has been made for the technical and interpretation component for the same procedure, same dates of service, same client, from any provider, the claim for the total component is denied as previously paid to another provider. The same is true if a total component is paid and subsequent claims are received for the individual components.
The following table summarizes procedure code limitations for laboratory services. The procedure codes in Column A are denied as part of another service when submitted with the same date of service by the same provider as any of the procedure codes in Column B.
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