Avalon Healthcare Solutions: Laboratory Medical Policy Pay and Educate Alerts

Avalon Healthcare Solutions: Laboratory Medical Policy Pay and Educate Alerts

8/26/2016

In an effort to improve adherence to medical policies for laboratory services filed for places of service (POS): Hospitals (POS 22 and 19), Physician Offices (POS 11) and Independent Laboratories (POS 81), you may receive an alert message on upcoming remittances. This pay and educate alert indicates that a specific test did not meet our medical policy criteria as well as the medical policy we used to make the determination. As of now, your claim payment will not be impacted, however, in the future, services may deny if the medical policies are not followed. 
 
What you should do:
  • Review your remittance advices for RARC N363: Alert: In the near future we are implementing new policies/procedures that would affect this determination.
  • Review the appropriate medical policy as indicated on your remit (example: CAM 130). Medical policies can be found at http://www.cam-policies.com/internet/cmpd/cmp/mdclplcy.nsf/dispDisclaimer?openform.
  • Avoid future denials by becoming familiar with the requirements for laboratory tests (example: frequency limitations, gender limitations, units, etc.)
  • Use the Avalon Lab Benefit Management Trial Claim Tool in My Insurance Manager prior to rendering services to determine whether a medical policy applies to your test.
    • This tool will allow you to use patient specific information (gender, diagnosis, date of birth, etc.) to determine if the service meets our medical policy criteria.
Please begin reviewing your remittances and work with your physicians, billers and administrative staff to ensure that this new process is incorporated in your business practices and to avoid future denials.
 
You can find more communications about Avalon by visiting our websites at www.SouthCarolinaBlues.com and www.BlueChoiceSC.com. Avalon is an independent company that provides a comprehensive suite of laboratory benefit management services on behalf of BlueCross and BlueChoice®. Should you have specific questions, please contact Provider Relations and Education by emailing provider.education@bcbssc.com. You may also contact Avalon at 855-895-1676 for additional information.