Referring Laboratories

50.1 - Referring Laboratories (Rev. 85, 02-06-04) B3-5114.1 Medicare recognizes that specimens drawn or collected by one laboratory are sometimes referred to another laboratory for testing. Payment for a Medicare-covered, referred laboratory service may be made under the rules established in Chapter 15 §40.1. The rules specified Chapter 15 §40.1 do not apply to services performed in a physician office laboratory or a qualified hospital laboratory. Both circumstances are entirely outside the scope of all sections concerning referral laboratory services. Every A/B MAC (B) shall process a claim for a referred laboratory service if submitted by an independent clinical laboratory with a physical presence within the A/B MAC (B)’s jurisdiction, notwithstanding that the referred laboratory service may have been performed outside of its jurisdiction. Every A/B MAC (B) shall maintain the clinical laboratory fee schedules for each A/B MAC (B) jurisdiction and be able to process claims using those fee schedules. Every A/B MAC (B) shall base payment for a referred service on the fee schedule for the jurisdiction in which the service was performed, i.e., where the test was performed. An exception to this rule allows a payment for a service that is A/B MAC (B)-priced to be based upon the price developed by the A/B MAC (B) processing the claim. Every A/B MAC (B) that has previously assigned “reference use only” PINs to out-of- jurisdiction laboratories for the purpose of their billing referred services shall cancel such “reference-use-only” PINs. A/B MACs (B) must use the numerical locality codes specified in 50.4 to identify the appropriate clinical diagnostic laboratory fee schedule for use in pricing a referred laboratory service.