BILLING

CLIENT BILLING

Quest Diagnostics Nichols Institute will bill your account either twice a month on the 15th and 30th or once a month on the 30th. The following information may be provided if submitted with the order:

  • Patient Name
  • Date of Service
  • Accession Number
  • Testing performed
  • CPT codes
  • Test Price
  • Patient/Lab ID
  • Referring Physician Name/Number
  • Purchase Order Number

Except as may otherwise be provided in this Agreement, Hospital agrees to pay Quest Diagnostics by payment of check, certified money order or electronic wire transfer or other form of payment method approved by Quest Diagnostics, within thirty (30) days of the date of each Quest Diagnostics invoice for Laboratory Services, after which any undisputed unpaid invoice amounts shall be overdue. Quest Diagnostics is unable to accept payment by credit card, debit card or any other instrument requiring the payment of service fees or other charges to a third party.

PHYSICIAN/CLIENT BILLING

An invoice is sent at the beginning of each month detailing the previous month’s services, unless Quest Diagnostics has agreed to an alternate billing cycle for your account. We have provided the American Medical Association’s (AMA) Current Procedural Terminology (CPT) codes for tests listed in this manual. It is the responsibility of the client to research and verify the accuracy of the CPT codes that they use for billing purposes. CPT guidelines are published by the AMA and are also available from many insurance carriers. This catalog lists CPT codes to provide some guidance, and is subject to change at any time. The CPT codes provided are based upon AMA guidelines and are for informational purposes only. CPT coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payor being billed.

ADDITIONAL FEES

In some instances, tests performed at Nichols Institute may require additional charges. These charges are for processing fees, infectious organism susceptibility reflexes and m-component identification.

PATIENT BILLING

If requested, or as required by law, Nichols Institute will bill patients directly within the Unites States. In this case, the Patient Fee Schedule will apply. These fees vary from those charged to physicians/clients. Panels and/or profiles that do not conform to specific CPT codes will be billed as the individual test components performed.

The patient’s full name and address must appear on the test request form. Many patients subsequently request insurance billing for those plans with which Nichols Institute participates. In those cases, diagnosis information will be required in order to file a claim and we will not accept a diagnosis from a patient so we will call your office. If a patient is enrolled with a health plan with which we participate, provide the applicable diagnosis information from an International Classification of Diseases (ICD) code manual and request Nichols Institute bill the insurance carrier. We participate with a variety of traditional insurance plans and managed care organizations (HMOs and PPOs). Please contact your sales representative for an up-to-date list of those plans. When appropriate, we will bill the patient upon receipt of a claim rejection. Insurance plans are billed at the same prices billed to patients.

THIRD PARTY AND CONTRACT BILLING

Nichols Institute may bill third party carriers directly if complete billing information is provided on the test request form or order screen. Your patient will be billed for amounts not covered or paid by their insurance. Check the third party billing box on the test request form. You must provide: the patient’s name, street address, city, state, zip code, area code/telephone number, date of birth, sex, referring physician name, UPIN, provider NPI code by specificity, the responsible party’s name and relationship to patient, ID or policy number and group number. Attach a copy of the patient’s insurance card to the request. If the required information is not provided, the client may be billed for payment. For a listing of insurance carriers contracted by Nichols Institute, please contact your account representative.

MEDICARE AND MEDICAID/MEDICAL

Nichols Institute may bill Medicare, MediCal and various Medicaid programs directly for clients other than hospitals. Check the appropriate billing box on the Medicare or Medicaid/MediCal test request form or electronic order screen. Provide the following information: patient name, address, city, state, zip code, phone number, date of birth, sex, Medicare or Medicaid/MediCal policy number, insurance card copy, ICD code by specificity, referring physician name and UPIN number for Medicare patients or referring physician Medicaid provider number for Medicaid/MediCal patients. The physician signature is required in some states in order to bill Medicaid.

MEDICARE

Under the Medicare statute, a laboratory must bill Medicare directly for clinical laboratory services. Physicians may not bill the Medicare program for laboratory tests they do not perform.

Clinical diagnostic laboratory tests are reimbursed on the basis of a fee schedule. The following procedures are exempted from fee schedule reimbursement:

  • Clinical Pathology Consultations
  • Blood Bank Services
  • Blood Smears with Written Interpretations
  • Certain Other Cytopathology Services
  • Bone Marrow Smears and Biopsies
  • Surgical Pathology Services

Medicare reimburses for these procedures at 80% of the approved amount and requires that the patient be billed for the remaining 20% copayment and any applicable deductible amounts.

When ordering tests for patients under Medicare, physicians or authorized individuals should only order tests that are medically necessary for the diagnosis and treatment of a patient, rather than for screening purposes. The Office of the Inspector General takes the position that a physician who orders medically unnecessary testing may be subject to civil penalties.

The Centers for Medicare and Medicaid Services (CMS) has implemented uniform National Coverage and Administrative Policies for clinical laboratory services that ensure the medical necessity of certain services rendered to Medicare beneficiaries. In addition to the National Coverage Policies subject to National Coverage Determination (NCD), CMS allows Medicare Contractors to develop their own Local Coverage Determination policies (LCD). These LCDs vary among Medicare carrier jurisdictions. Many of the procedures subject to NCD or LCD are for clinical laboratory testing. These tests are often referred to as Limited Coverage Tests.

Medicare Contractors require medical necessity documentation in order to determine coverage for tests that are subject to NCD or LCD. A carrier will deny coverage for a limited coverage test when it is submitted without specific diagnosis information that supports the medical necessity for the testing. Documentation of medical necessity for laboratory tests is reported to the carrier with a code from the International Classification of Diseases (ICD). ICD manuals are available from various publishers.

Whenever you order a test that is subject to NCD or LCD, an ICD code is required on the test request form. The ICD code should indicate the medical necessity that you believe is appropriate for the test. Please provide the ICD code that most accurately describes the patient’s condition. Do not choose a code merely to secure claim payment. ICD codes must be provided in valid format, including 4th and 5th digit specificity when required. The ICD code that you provide must appear in the patient’s medical records in order to support the necessity of the testing in the event of a post-payment review.

Whenever possible, tests that are subject to NCD or LCD established by Nichols Institute’s Medicare carrier are printed in red on the test request forms. The Medicare carrier may adopt additional LCD for other tests at any time. Copies of our Medicare carrier’s LCD are available. We will advise you of new LCD or updates whenever they are issued.

ADVANCE BENEFICIARY NOTICE

In the event that a test is determined by Nichols Institute’s Medicare carrier to be medically unnecessary, the laboratory may only bill the patient if an Advance Beneficiary Notice (ABN) has been completed and signed by the patient before the time that the specimen is collected. Medicare’s medical necessity requirements for coverage may not always be consistent with the reasons why you believe a test is appropriate for a patient. Nevertheless, when you have reason to believe that a test may be considered medically unnecessary by Medicare, the patient should be asked to sign a completed ABN. A new ABN must be completed and signed each time such conditions exist. An ABN signature may not be requested solely on the basis that a test being ordered is subject to NCD or LCD.

The ABN ensures that the patient understands that he/she will be responsible to pay for any services marked on the form that Medicare does not cover for one of the following reasons:

  • The test is subject to NCD or LCD and the diagnosis for which the test is ordered is not considered to be indicative of medical necessity by Medicare.
  • The test is ordered more frequently than Medicare considers medically necessary.
  • The test is for research or investigational use only and is not approved by the Food and Drug Administration.

All of the information on the ABN must be completed. The test(s) that you believe will be considered by Medicare to be medically unnecessary must be clearly marked. If you must write in a test name on the ABN, please write the test name as it appears on the test request form. Do not use synonyms or abbreviations.

Please be sure that the patient reads, understands, and signs the ABN prior to the specimen being collected. The form must be dated and the date should correspond to the date on which the specimen is collected. If the patient is unable to sign, the form should be marked with an “X” and the patient’s guardian, guarantor, or other responsible party should sign the form.

ABN forms are available for those clients who order Medicare tests electronically. A bar code label for the accession related to the ABN should be placed in the upper right hand corner of the ABN. The completed ABNs should be placed in a separate envelope and sent directly to the billing department via your daily courier service. Please see the request form’s completion instructions for more information.

MEDICAID

Nichols Institute participates with several state Medical Assistance programs. As with Medicare, most Medicaid programs do not allow physicians to file claims for services they do not perform. If the patient is enrolled with an additional insurer, such as Medicare or a private carrier, Medicaid can only be billed after those parties have been billed. Please be sure to provide all necessary billing information on the request form, including the ordering physician’s original signature and Medicaid provider identification number. In cases where the patient is enrolled in a Medicaid HMO program, please verify that we are a participating provider with that program before submitting specimens for testing.

Medicaid carriers require diagnosis information in order to process a claim. This information is reported to carriers with a code from the International Classification of Diseases (ICD). ICD manuals are available from various publishers. Diagnosis information should be provided in ICD format when Medicaid billing is requested.