Regional Pathology Services
Reviewed/Revised: April 2017
Client billing is the most efficient way to order laboratory testing from Regional Pathology Services. Client billing eliminates the need for you to provide current patient demographic and insurance information, resulting in the simplification of the ordering and testing process, thus eliminating delays.
Third Party/Insurance Billing/Information required with a laboratory test request
Regional Pathology Services provides billing service for Medicare/Medicaid and/or third party payers. Each test request form must include (either printed legibly on the form or as an attachment) patient demographic information including address, telephone, social security # (if applicable), date of birth, complete insurance information including the patient/guarantor name and address, policy and group #, and the effective date of insurance, or a copy of the patients insurance card may be attached to the laboratory test request form. Guarantor information including the date of birth is required if the patient is a minor. The test request form must also contain the appropriate diagnosis narrative or an ICD-10 code, ordering provider, and the collection date of the specimen(s). The submission of a test request form with an incomplete patient billing information may result in testing delay.
Please note: Midlands Choice requires the employer name to be listed on all claims. Please include the employer information on all Midlands Choice patient test request forms.
The ordering/referring provider listed on a claim for laboratory services must be enrolled in the Medicare program. There will be claim edits to determine if the ordering/referring provider has a current Medicare enrollment record and contains a valid National Provider Identifier (NPI), and is of a provider type that is eligible to order or refer for a Medicare beneficiary.
Date of Service
Regional Pathology Services will use the collection date provided by the submitter of each specimen as the date of service for all clinical and anatomic laboratory testing. This includes: automated clinical laboratory tests, biopsy specimens, lymphoma and/or leukemia flow cytometry panels. Regional Pathology Services will use the date received as the date of service for anatomic consultation specimen(s). Archived material/slides that are pulled from storage for additional testing will have the date of service listed as the date the request was received to pull the material/slides.
ICD-10 (Diagnosis) Information
All clinical laboratory claims must include a valid ICD-10 diagnosis code (to the highest level of specificity) or narrative. The code must be supplied by the ordering provider. It is the responsibility of Regional Pathology Services to report the code provided. If no code or narrative is supplied, the Regional Pathology Billing Department staff will contact the ordering provider and request the information. Please remember to code signs or symptoms, do not use “rule out” or “probable” as a diagnosis. The accuracy of the diagnosis information accommodates prompt reimbursement to Regional Pathology Services when filing insurance claims.
Medicare Facility (Hospital) In-Patient/Out-Patient Billing for Anatomic Pathology
For the Medicare In-Patient: All technical components will be billed back to the client. The technical components will be paid by Medicare to the institution that the patient is registered as an in-patient through the DRG (Diagnosis Related Group) payment. The professional fee will be billed to Medicare by Regional Pathology Services.
For the Medicare Registered Out-Patient: (The patient has been admitted for services as an observation patient, which will include diagnostic services in other areas of the facility). All technical components will be billed back to the client. The technical components will be paid by Medicare to the institution that the patient is registered as an out-patient through the APC (Advanced Payment Classification) payment. The professional fee will be billed to Medicare by Regional Pathology Services.
For the Medicare Out-patient: (The patient that is coming to the institution for laboratory services), both the technical and the professional fee components will be billed to Medicare by Regional Pathology Services.
Medicare Patient in Skilled Nursing/Hospice
Regional Pathology Services bills as a hospital- based laboratory, therefore Medicare services must adhere to the following billing regulations for clinical laboratory billing.
For the Medicare/Skilled Nursing Facility Patient/Hospice Patient
Skilled Nursing Facility
When a patient is residing in a skilled nursing facility and visits a physician office, any orders for laboratory should be directed back to the skilled nursing facility for processing. Regional Pathology Services is unable to bill Medicare direct for laboratory services while the patient is in skilled care.
Regional Pathology Services will bill the client who submitted the clinical laboratory test while the Medicare patient resides in the hospice facility.
Medicare 72 Hour Rule
A client may request that Regional Pathology Services bill Medicare for the technical charges for testing performed within 72 hours of the admission of a patient as an in-patient or registered out-patient. Regional Pathology Services receives notification from Medicare that payment was billed/received by the institution where the patient was registered. Regional Pathology Services will bill back the technical charges to the client who submitted the specimen.
Insurance Carriers with HMO (Health Maintenance Organization)
“An organization that provides health coverage with providers under contract. A Health Maintenance Organization (HMO) differs from traditional health insurance by the contracts it has with its providers. These contracts allow for premiums to be lower, because the health providers have the advantage of patients directed to them; but these contracts also add additional restrictions to the HMO's members.”
Restrictions are typically limited when choosing Regional Pathology Services. Because RPS bills under the tax ID# of Nebraska Medicine for all technical claims, and UNMC Physicians for all professional claims, the guidelines for these entities are followed regarding contracted insurance carriers and/or HMO insurance organizations.
A review of an insurance card, or checking with the patient when submitting laboratory specimens can save time and additional costs for the patient and/or client. If the patient has an HMO insurance, or an insurance type that requires prior authorization for certain laboratory testing, please be aware that there are specific regulations in order to bill for these services. If the client requests RPS to bill insurance, payment will be denied and services become the responsibility of the client, or at the client request, may be billed to the patient at a higher out of pocket/deductible expense for these services
Regional Pathology Services will bill Medicare for services. Please ensure that the patient demographic and insurance information is submitted with the requisition, along with the diagnosis code for clinical laboratory testing. This information enhances the timeliness of claim submission and payment for Regional Pathology Services.
Regional Pathology Services will bill Medicaid for services when appropriate demographic and Medicaid information is received for services. All Medicaid eligibility is verified prior to billing. If the patient is not eligible, the patient will be treated as a self-pay patient and the services will be billed to the client. Regional Pathology Services limits Medicaid claims for Nebraska, Iowa, Colorado, Kansas and South Dakota only.
Coventry Health Care of Nebraska
Recent published information from Coventry issued a list of genetic testing (which includes molecular studies performed through Regional Pathology Services) that requires prior authorization. A list of the CPT codes with this requirement can be obtained by contacting Regional Pathology Services billing department (402) 559-7283 or sending an email to firstname.lastname@example.org If a prior authorization is not received along with the requisition when the patient is covered under Coventry Health Care of Nebraska, is will be necessary to bill you as a client for the molecular studies performed. A few examples of molecular studies are: Gene rearrangement studies, JAK-2, T-Cell studies, Cystic Fibrosis testing, Norwalk Virus and Newborn Hgb Electrophoresis. While this does not encompass every molecular test, it is a good example of some studies that require prior authorization. To obtain a list of prior authorization requirements, visit www.directprovider.com or www.chcnebraska.com or to obtain a prior authorization, please call (800) 471-0240 Ext. 7718 or Fax (866) 769-2399.
Wellmark BCBS of Iowa (HMO)
There are several alpha prefix codes to identify Iowa Wellmark BCBS HMO including XQW and XQZ, but are not limited to those prefixes only. If an ordering provider/client requests Regional Pathology Services to provide reference laboratory work to Wellmark BCBS of Iowa, the services will be billed back to the client.
Pre-Operative Clinical Laboratory Testing
When ordering a pre-operative clinic laboratory test, the ICD-10 code submitted must include the condition/reason for the patient’s surgery, in addition to the pre-operative ICD-10 code Z01.812 (pre-operative laboratory).
Regional Pathology Services may receive denials for reimbursement from an insurance payer. Every attempt will be made to collect the appropriate payment from the insurance company. When collection attempts fail, Regional Pathology Services may bill the client for the services that are not payable by the particular insurance company.
Self Pay Patients
Regional Pathology Services prefers to bill the client for all self-pay patients.
Advanced Beneficiary Notice (ABN)
Advance Beneficiary Notice (ABN) is a Medicare requirement for all tests that are deemed not to meet medical necessity according to the diagnosis code chosen. Whenever a test is ordered that is not considered medically necessary according to the National or Local Coverage Determination, the patient must sign an ABN prior to collection of the specimen. A copy of the signed ABN must be attached to the test request form that accompanies the specimen to Regional Pathology Services. For testing that is submitted without a proper diagnosis code, the billing staff will contact the client for a valid diagnosis code. If a test fails medical necessity, two attempt to retrieve a valid diagnosis code will be submitted to the client via fax or email. If no response from the client, the associated fee for testing will become the responsibility of the client.
Participating Insurance Companies
For a current list of participating insurance companies, visit our website at www.reglab.org, click on the Billing/Compliance tab, then click on the Participating Insurance Plans tab to view the listing.
Please call the Regional Pathology Services billing department if questions regarding specific payers. 1-402-559-9480; Toll free at 1-877-560-0009
Client Billing Collection Policy
Invoices will process and print during the first week of each month and will be sent to you upon our receipt of the printed invoices. Invoices should be paid in full within 60 days. Regional Pathology Services will review accounts on a regular basis and for those clients not in compliance with our payment policies, written notice will be submitted that we may not accept any further specimens for testing until payment in full is received. If you have charges on your invoice that you feel are incorrect, please refer to the name and telephone number on the invoice to call with any questions/concerns.