Effective Jan. 1, 2025, EmblemHealth will introduce a new Laboratory/Venipuncture Reimbursement Policy that is aligned with CMS and Federal Clinical Laboratory Improvement Amendments’ (CLIA) regulations. EmblemHealth will only reimburse you for laboratory services you are certified to perform through the Federal CLIA Laboratory Program. EmblemHealth will consider reimbursement of CLIA waived laboratory tests for its network physicians when performed in their office. CLIA waived laboratory tests are allowed with a CLIA Waiver and do not require a certificate of accreditation or compliance.
Billing tips: All claims billed on a CMS 1500 Health Insurance Claim Form, or its electronic equivalent, must include a valid Federal CLIA Certificate Identification number. If the claim is for a CLIA waived test, the Modifier QW must be used.
The following reimbursement policy has been updated. This policy applies to both EmblemHealth and ConnectiCare. See revision history for effective dates and applicable changes:
The following updates are being made to the Lab Benefit Management program. We are introducing a new Serum Testing for Evidence of Mild Traumatic Brain Injury (LBM) policy and are making updates as shown in the revision histories to the following policies:
- B-Hemolytic Streptococcus Testing (LBM).
- Biochemical Markers of Alzheimer Disease and Dementia (LBM).
- Biomarkers for Myocardial Infarction and Chronic Heart Failure (LBM).
- Bone Turnover Markers Testing (LBM).
- Cardiovascular Disease Risk Assessment (LBM).
- Celiac Disease Testing (LBM).
- Cervical Cancer Screening (LBM).
- Diagnostic Testing of Common Sexually Transmitted Infections (LBM).
- Diagnostic Testing of Influenza (LBM).
- Epithelial Cell Cytology in Breast Cancer Risk Assessment (LBM).
- Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing (LBM).
- Fecal Calprotectin Testing in Adults (LBM).
- Flow Cytometry (LBM).
- Folate Testing (LBM).
- Gamma-glutamyl Transferase (LBM).
- General Inflammation Testing (LBM).
- Hepatitis Testing (LBM).
- Identification of Microorganisms Using Nucleic Acid Probes (LBM).
- Immunopharmacologic Monitoring of Therapeutic Serum Antibodies (LBM).
- In Vitro Chemoresistance and Chemosensitivity Assays (LBM).
- Lab Testing for the Diagnosis of IBD (LBM).
- Measurement of Thromboxane Metabolites for ASA Resistance (LBM).
- Metabolite Markers of Thiopurines Testing (LBM).
- Nerve Fiber Density Testing (LBM).
- Oral Cancer Screening and Testing (LBM).
- Pancreatic Enzyme Testing for Acute Pancreatitis (LBM).
- Pathogen Panel Testing (LBM).
- Prenatal Screening-Nongenetic (LBM).
- Prostate Biopsy Specimen Analysis (LBM).
- Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease (LBM).
- Serum Tumor Markers for Malignancies (LBM).
- Testing for Alpha-1 Antitrypsin Deficiency (LBM).
- Testing for Diagnosis of Active or Latent Tuberculosis (LBM).
- Testing for Vector-Borne Infections (LBM).
- Thyroid Disease Testing (LBM).
- Urine Culture Testing for Bacteria (LBM).
- Venous Thrombosis Risk Testing (LBM).
JP 67788 12/2024
