Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 06|16|2009 POLICY LAST UPDATED: 09|07|2022 OVERVIEW
This administrative policy is to document payment by date of service (DOS) for laboratory specimens. Blue Cross Blue Shield of Rhode Island will follow CMS guidelines regarding the date of service of laboratory specimens. MEDICAL CRITERIA Not Applicable PRIOR AUTHORIZATION Not Applicable POLICY STATEMENT The DOS of the test shall be the date the specimen was collected. However, if a specimen is collected over a period that spans two calendar days, then the DOS shall be the date the collection ended.
The following two exceptions apply to the DOS policy for laboratory tests: A. DOS for Tests Performed on Stored Specimens: In the case of a test performed on a stored specimen, if a specimen was stored for less than or equal to 30 calendar days from the date it was collected, the DOS of the test must be the date the test was performed only if:
• The test is ordered by the patient’s physician at least 14 days following the date of the patient’s discharge from the hospital; • The specimen was collected while the patient was undergoing a hospital surgical procedure; • It would be medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was admitted; • The results of the test do not guide treatment provided during the hospital stay; and • The test was reasonable and medically necessary for treatment of an illness. If the specimen was stored for more than 30 calendar days before testing, the specimen is considered to have been archived and the DOS of the test must be the date the specimen was obtained from storage.
B. DOS for Chemotherapy Sensitivity Tests Performed on Live Tissue: In the case of a chemotherapy sensitivity test performed on live tissue, the DOS of the test must be the date the test was performed only if:
• The decision regarding the specific chemotherapeutic agents to test is made at least 14 days after discharge; • The specimen was collected while the patient was undergoing a hospital surgical procedure; Payment Policy | Date of Service for Laboratory Specimens

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

• It would be medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was admitted;
• The results of the test do not guide treatment provided during the hospital stay; and
• The test was reasonable and medically necessary for treatment of an illness.

For purposes of applying the above exception, a “chemotherapy sensitivity test” is defined as a test that requires a fresh tissue sample to test the sensitivity of tumor cells to various chemotherapeutic agents. CMS identifies such tests through program instructions issued to the Medicare contractors.1

COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage or Subscriber Agreement for applicable laboratory testing benefits/coverage.

BACKGROUND This administrative policy is to document payment by date of service (DOS) for laboratory specimens.

CODING Not Applicable

RELATED POLICIES None

PUBLISHED Provider Update, November 2022 Provider Update, December 2019

REFERENCES: i1. Accessed 6/4/09: http://www.cms.hhs.gov/transmittals/downloads/R1319CP.pdf.

2. Lusky, K. Wins, worries on reimbursement battlefields. College of American Pathologists;2008 Archive. Accessed on June 4, 2009: http://www.cap.org.

3. Office of Inspector General. Review of Medicare Payments to VNA Care Network, Inc., for home health services preceded by a hospital discharge. July 2007. Accessed on June 4, 2009: http://www.oig.hhs.gov/oas/reports/region1/10600514.pdf.

4. U.S. Government Publishing Office. Title 42 - Public Health Chapter IV - CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES Subchapter B - MEDICARE PROGRAM Part 414 - PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Subpart G - Payment for New Clinical Diagnostic Laboratory Tests Section 414.510 - Laboratory date of service for clinical laboratory and pathology specimens. Accessed 9/26/19: https://www.govinfo.gov/content/pkg/CFR-2012-title42-vol3/pdf/CFR-2012-title42-vol3-sec414-510.pdf

   This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS