Special Provisions for Lab ADRs

3.2.3.7 - Special Provisions for Lab ADRs (Rev.: 13008; Issued: 12-18-24; Effective: 01-17-25; Implementation: 01-17-25) This section applies to MACs, CERT, RACs, UPICs, and SMRC as indicated. ICD-10-CM is used for diagnoses on inpatient discharges and for other services provided upon implementation of ICD-10. When the MACs, CERT, RACs, SMRC, and UPICs send an ADR for a lab service, the following documentation shall be requested from the billing lab: • The order for the service billed (including sufficient information to allow the reviewer to identify and contact the ordering provider); • Verification of accurate processing of the order and submission of the claim; and • Diagnostic or other medical information supplied to the lab by the ordering provider, including any diagnosis codes or narratives. The contractor shall deny the claim if a benefit category, statutory exclusion, or coding issue is in question, or send an ADR to the ordering provider to determine medical necessity. The contractor shall review information from the lab and find it insufficient before the ordering provider is contacted. The contractor shall send an ADR to the ordering provider that shall include sufficient information to identify the claim in question. If the documentation received does not demonstrate that the service was reasonable and necessary, the contractor shall deny the claim. These denials are considered medical record reviews. Contractor denial notices shall remind providers that beneficiaries cannot be held liable for these denials unless they received proper liability notification before services were rendered, as detailed in CMS Pub. IOM 100-04, chapter 30.