|
Radiology and Laboratory Services Handbook
Table of Contents
1. General Information RL-5
2. Independent Laboratory RL-5
2.1 Enrollment RL-5
2.1.1 Clinical Laboratory Improvement Amendments (CLIA) RL-5
2.1.2 CLIA Requirements RL-6
2.2 Services, Benefits, Limitations and Prior Authorization RL-6
2.2.1 CLIA Certificates RL-6
2.2.2 Laboratory Handling Fees and Reference Laboratories RL-7
2.2.2.1 Independent Laboratory Providers RL-7
2.2.2.2 Physician Providers RL-7
2.2.2.3 Outpatient Hospital Providers RL-8
2.2.2.4 Family Planning Laboratory Tests RL-8
2.2.3 Clinical Laboratory Procedures RL-8
2.2.3.1 Repeat Procedures RL-11
2.2.4 Nonclinical Laboratory Procedures RL-11
2.2.4.1 Repeated Procedures RL-12
2.2.5 Automated Laboratory Tests and Laboratory Paneling RL-12
2.2.5.1 Automated Laboratory Tests RL-12
2.2.5.2 Laboratory Panels RL-13
2.2.5.3 Fee Calculations for Automated Tests and Laboratory Panels RL-13
2.2.6 Complete Blood Count (CBC) RL-15
2.2.7 Genetic Testing for Colorectal Cancer RL-16
2.2.7.1 Authorization Requirements RL-17
2.2.8 Human Immunodeficiency Virus (HIV) Drug Resistance Testing RL-18
2.2.9 Iron Studies RL-19
2.2.10 Urinalysis RL-20
2.2.11 Additional Laboratory Services RL-21
2.2.11.1 BRCA Testing RL-21
2.2.11.2 Colorectal Cancer Screening RL-21
2.2.11.3 Cytopathology Studies RL-21
2.2.11.4 Helicobacter pylori Testing RL-21
2.2.11.5 Laboratory Services for Clients on Dialysis RL-21
2.2.11.6 Prognostic Breast and Gynecological Cancer Studies RL-21
2.2.11.7 Services Incidental to Surgery and/or Anesthesia RL-21
2.2.11.8 THSteps Outpatient Laboratory Services RL-22
2.2.11.9 Authorization Requirements RL-22
2.3 Documentation Requirements RL-22
2.4 Claims Filing and Reimbursement RL-22
2.4.1 Claims Information RL-22
2.4.1.1 Electronic Filing for Laboratory Providers RL-22
2.4.2 Reimbursement RL-23
3. Radiological and physiological laboratory services RL-23
3.1 Enrollment RL-23
3.1.1 Enrollment Criteria for Mammography Providers RL-23
3.2 Services, Benefits, Limitations, and Prior Authorization RL-24
3.2.1 Cardiac Nuclear Imaging RL-24
3.2.1.1 Authorization Requirements RL-25
3.2.2 Computed Tomography and Magnetic Resonance Imaging RL-25
3.2.2.1 Functional MRI (fMRI) RL-25
3.2.2.2 Intraoperative MRI (iMRI) RL-26
3.2.2.3 Authorization Requirements and Flexibility RL-26
3.2.3 Positron Emission Tomography (PET) Scan Imaging RL-27
3.2.3.1 Authorization Requirements RL-28
3.2.4 Physician-Performed Radiology Services RL-28
3.2.5 Authorization Requirements for CT, CTA, MRI, fMRI, MRA, PET, and Cardiac
Nuclear Imaging Services RL-28
3.2.5.1 Retroactive Authorization RL-30
3.2.5.2 Request Form and Documentation RL-31
3.2.5.3 Methods of Submission RL-32
3.2.6 Additional Radiology and Physiological Laboratory Services RL-32
3.2.6.1 Ambulatory Electroencephalogram RL-32
3.2.6.2 Brachytherapy RL-32
3.2.6.3 Diagnostic Doppler Sonography RL-32
3.2.6.4 Electrocardiograms RL-33
3.2.6.5 Electromyography (EMG and Nerve Conduction Studies (NCS)) RL-33
3.2.6.6 Esophageal pH Probe Monitoring RL-33
3.2.6.7 Mammography Services RL-33
3.2.6.8 Nonsurgical Vision Services RL-33
3.2.6.9 Obstetric Services RL-33
3.2.6.10 Radiation Therapy Services RL-33
3.2.6.11 Screening and Diagnostic Studies of the Breast RL-33
3.2.6.12 Services Incidental to Surgery and/or Anesthesia RL-33
3.2.6.13 Sleep Studies RL-34
3.3 Documentation Requirements RL-34
3.4 Claims Filing and Reimbursement RL-34
3.4.1 Claims Information RL-34
3.4.1.1 Diagnosis Requirements RL-34
3.4.1.2 Modifier Requirements for Type of Service Assignment RL-35
3.4.2 Reimbursement RL-35
4. Claims Resources RL-36
5. Contact TMHP RL-36
6. Forms RL-36
RL.1 Radiology Prior Authorization Request Form RL-37
8. Claim Form Examples RL-38
RL.2 Independent Laboratory RL-39
RL.3 Office Visit with Lab and Radiology RL-40
RL.4 Radiological/Physiological Laboratory and Portable X-Ray Supplier RL-41
|
|
