Unit 5: Outpatient Radiology and Laboratory
Providers must refer members to participating laboratory vendors when molecular/genetic lab services are needed and are not performed in the provider’s office.
Prescription Necessary
PCPs and specialists need only give their members a prescription for the necessary lab tests and direct them to a network-participating lab.
Communication Between the PCP and Specialist
Specialty practitioners should communicate with a member’s PCP after a consultation visit so that laboratory services can be appropriately coordinated.
Pass-Through Billing Not Permitted
Pass-through billing occurs when ordering practitioners bill for clinical laboratory tests that were not performed in their offices. In Pennsylvania and Delaware, Highmark does not permit pass-through billing.
Practitioners should bill only for the component of the laboratory service they perform in their offices. Independent laboratories should bill for any clinical lab tests referred to them by practitioners.
Highmark will reimburse practitioners for drawing or handling when the specimen is sent to a laboratory other than the practitioner’s office lab and the clinical lab test is billed by the independent laboratory. However, if the clinical lab test is performed in the practitioner’s office and the practitioner bills for the test, an additional charge for drawing or handling will not be reimbursed. The handling or drawing of the specimen is considered part of the laboratory procedure.
Highmark is engaging HealthHelp, a specialty benefit management company, to assist Highmark in applying evidence-based medical criteria and expert peer consultation to ensure appropriate utilization of molecular lab services.
Procedures Requiring Authorization
Under Highmark’s Laboratory/Genetic Testing UM Program, Highmark requires prior authorization for molecular/genomic tests when performed in an outpatient setting for fully insured Commercial, Affordable Care Act (ACA), CHIP, and Medicare Advantage (MA) members.
These tests include:
- Cardiovascular disease and thrombosis risk variant testing
- Carrier screening tests
- Hereditary cancer screening
- Hereditary cardiac disorders
- Intellectual disability/developmental disorders
- Mitochondrial disease testing
- Neurologic disorders
- Pharmacogenomic testing
- Tumor marker/molecular profiling
A complete list of impacted procedure codes is available on HealthHelp's dedicated webpage for Highmark providers.
Any services performed without prior authorization may be denied, and providers may not seek reimbursement from members.
Exclusions
Prior authorization is not required for the following:
- Inpatient genetic testing
- General lab testing
- Genetic testing for CPT codes not included on the prior authorization list.
Requesting Authorizations
Highmark recommends that ordering physicians obtain authorizations and provide the authorization number(s) to the rendering facility when scheduling services. Authorizations include an authorization number and one or more CPT codes that correspond to the approved services.
Providers should submit authorization requests electronically through Availity Essentials.
If you are unable to submit authorization requests through Availity, you can submit authorization requests to HealthHelp by calling 877-820-7134 or faxing 877-514-0067.
Authorizations are valid for 180 days. If the approved procedure is not completed by the Last Assigned Covered Day, a new request must be submitted.
Urgent Requests
For medically urgent services needed within 48 hours, call HealthHelp at 877-820-7134 to request authorization. Be sure to tell the representative that the request is medically urgent/expedited so it can be flagged appropriately.
HealthHelp will make every effort to issue a determination within one business day after receiving all required clinical information.
For More Information
For additional program information, see the Laboratory Management information on the Provider Resource Center (PRC).
Inpatient vs. Outpatient
When you submit claims to Highmark for diagnostic or therapeutic radiology services or diagnostic medical services provided to hospital inpatients or outpatients, you must report the place of service as inpatient hospital or outpatient hospital, as appropriate. In these cases, you will be reimbursed only the professional component of the service.
- Inpatient – a patient who is an inpatient of a facility, such as a hospital or skilled nursing facility, at the time the procedure is performed. When an inpatient is taken outside the hospital setting, such as to a physician’s office, and is then returned to the hospital, the physician must report services according to the patient’s status, in this case, inpatient. Therefore, you must report only “inpatient” as the place of service, rather than the place, such as “office” or “outpatient hospital,” where the service actually was performed.
- Outpatient – a patient, other than an inpatient, who is treated in a hospital, on hospital grounds, or in a hospital-owned or controlled satellite, when it has been determined that the satellite is an outpatient department of the hospital. This definition does not apply when a treating physician’s sole practice is located in a hospital or hospital-owned building, if the practice is not affiliated or controlled, in any way, by the hospital or a related entity; or, if the practice has been approved to be recognized as an office practice.
For example, if a mobile ultrasound, MRI, or CT unit locates on hospital grounds one day each week, all services provided to patients on that day must be reported with inpatient or outpatient, but not office, as the place of service.
Highmark offers optional benefit designs that include cost-sharing provisions specific to outpatient diagnostic services.
Services Affected
Cost sharing on outpatient diagnostic services will be applied to:
- Routine/preventive diagnostic services (with the exception of all mammograms and the annual routine Pap test), and
- Non-routine diagnostic services, including pre-admission testing.
Impacted Products
Products that may have a cost-sharing benefit design include Exclusive Provider Organization (EPO) and Preferred Provider Organization (PPO) plans, including Medicare Advantage PPO.
Note: Cost-sharing provisions will not be noted on Member ID cards. Please review member benefits accordingly through Availity Essentials® or by contacting Provider Service if you are not an Availity-enabled provider.
Five Categories of Outpatient Diagnostic Services
Advanced Imaging Services:
- Advanced Imaging Services – include, but are not limited to, computed tomography (CT), computed tomography angiography (CTA), magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), positron emission tomography (PET scan), and positron emission tomography/computed tomography (PET/CT scan).
Basic Diagnostic Services:
- Standard Imaging Services – procedures such as skeletal X-rays, ultrasound, and fluoroscopy.
- Diagnostic Medical Services – procedures such as stress echocardiography, myocardial perfusion imaging (MPI), electrocardiograms (ECG), pulmonary studies, echocardiograms, electroencephalograms (EEG), regular treadmill stress tests, and audiology tests.
- Laboratory and Pathology Services – procedures such as non-routine Papanicolaou (Pap) smears, blood tests, urinalysis, biopsies, and cultures.
- Allergy Testing Services – allergy testing procedures such as percutaneous tests, intracutaneous tests, and patch tests.
How Coinsurance is Applied
If a member has coinsurance, it is applied to all line items identified as outpatient diagnostic services either on Advanced Imaging only or also on the four categories of Basic Diagnostic Services depending on the benefit design selected. The coinsurance amount (e.g., 80%) for the four categories of Basic Diagnostic Services is the same. Coinsurance for outpatient diagnostic services is applicable to the total component, technical component, and/or professional component only.
The member may be responsible for both a copayment and coinsurance when a service, such as an office visit or therapy service, and an outpatient diagnostic service are performed on the same date of service.
How Copayments are Applied
If a member has copayments on outpatient diagnostic services, they are applied per date of service and per type of diagnostic service. If services fall in more than one of the five diagnostic service categories (see above chart), multiple copayments can be applied. Please review the member’s benefit program to determine if a copayment is owed on multiple services.
Copayments may be applicable to only the advanced imaging services or also to all four categories of basic diagnostic services. The copayment amount for the advanced imaging services would usually be a higher amount (e.g., $100). The copayment amount for the four categories of basic diagnostic services is the same (e.g., $25 for each type of service).
Copayments are applied to the total component or technical component claims for outpatient diagnostic services. Copayments are not applied to professional component only claims (26 modifier).
Note: For Medicare Advantage products with outpatient diagnostic copayments, copayments are applied per date of service, per type of diagnostic service, and per provider.
Examples of Multiple Copayments and/or Coinsurance
- If a PPO member sees his cardiologist and receives an EKG during the visit, he would be responsible for two copayments: an office visit copayment and an outpatient diagnostic service copayment for the EKG (diagnostic medical service).
- If a PPO member receives an MRI (advanced imaging service), then has a spinal X-ray (standard imaging service) and lab work (laboratory/pathology service) on the same day – all as outpatient services – she would be responsible for three outpatient diagnostic copayments.
- If an EPO member sees his cardiologist and receives a regular treadmill stress test (basic diagnostic medical service) while there, he would pay an office visit copayment, and then would be responsible for any applicable coinsurance when the stress test claim is processed.
- If a Medicare Advantage member with outpatient diagnostic copayments sees her cardiologist and receives an EKG (basic diagnostic medical service) while there and on the same day goes to another physician and receives a regular treadmill stress test (also a basic diagnostic medical service), she would be responsible for two copayments, one for each provider.
Cost Sharing Exceptions
- All mammograms (routine and medically necessary) and the annual routine Pap tests are generally unaffected by the cost sharing benefit designs.
- Diagnostic services performed in conjunction with an emergency room visit would not be impacted in most cases.
- There may be situations where cost sharing may apply in the first two situations, especially for self-insured employer groups. Please be sure to review each service on a case-by-case basis.
Determining if Members have Cost-Sharing
More information on outpatient radiology and other diagnostic services cost sharing can be easily accessed through Availity by selecting the appropriate service type, or by contacting the Provider Service Center if you are not an Availity-enabled provider.
To verify outpatient diagnostic benefits in Availity, select Additional Benefit Notes from the Eligibility and Benefits detail page.
The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life, Highmark Care Benefits Inc., or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield. West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company. Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield. Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.
All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies.
All revisions to this Highmark Provider Manual (the “manual” or “Highmark Provider Manual”) are controlled electronically. All paper copies and screen prints are considered uncontrolled and should not be relied upon for any purpose.
