General Rate Provisions and Maximum Fees

(1) Rate Determination. Payment rates are the lowest of (a) the eligible provider's usual and customary charge to patients other than publicly aided individuals or industrial accident patients; (b) the applicable listing from the schedule of allowable fees listed in 101 CMR 320.05; or (c) the amount that is allowable under 42 U.S.C. § 1396b(i)(7). (2) Individual Consideration (IC). Unlisted procedures and laboratory tests designated IC are individually considered items. The eligible provider's bill for such a test must be accompanied by a brief report of the procedure or test performed and the eligible provider's usual and customary charge for that procedure or test. Determination of appropriate payments for procedures and tests designated IC are in accordance with the following standards and criteria: (a) time required to perform the procedure; (b) degree of skill required in the procedure performed; (c) severity or complexity of the patient's disease, disorder, or disability; (d) policies, procedures, and practices of other third-party purchasers of care; (e) prevailing medical-laboratory ethics and accepted custom of the medical-laboratory community; and (f) such other standards and criteria as may be adopted by EOHHS. In no event may an eligible provider bill or be paid in excess of the usual and customary charge for the service. (3) Administrative and Supervisory Duties. The rates of payment under 101 CMR 320.00 are full compensation for clinical laboratory services rendered to publicly aided individuals, as well as any related administrative or supervisory duties in connection with clinical laboratory services, without regard to where the service is rendered. (4) Profile (or Panel) Tests. In no event may an eligible provider bill or be paid separately for each of the tests included within a profile test when a profile test has either been performed by the provider or requested by an authorized person. (5) Limitations on Payment for Panel Tests. (a) Any combination of the following tests when performed on a single patient on a single date of service is regarded as a single panel test: 80047 Basic Metabolic Panel -calcium, ionized (Consists of 82330, 82374, 82435, 82565, 82947, 84132, 84295, 84520): eight individual tests 80048 Basic Metabolic Panel -calcium, total (Consists of 82310, 82374, 82435, 82565, 82947, 84132, 84295, 84520): eight individual tests 80051 Electrolyte Panel (Consists of 82374, 82435, 84132, 84295): four individual tests 80053 Comprehensive Metabolic Panel (Consists of 82040, 82247, 82310, 82374, 82435, 82565, 82947, 84075, 84132, 84155, 84295, 84460, 84450, 84520): 14 individual tests 80061 Lipid Panel (Consists of 82465, 83718, 84478): three individual tests 80069 Renal Function Panel (Consists of 82040, 82310, 82374, 82435, 82565, 82947, 84100, 84132, 84295, 84520): ten individual tests 80076 Hepatic Function Panel (Consists of 82040, 82247, 82248, 84075, 84155, 84460, 84450): seven individual tests 82040 Albumin; serum 82247 Bilirubin; total 82248 Bilirubin; direct 82310 Calcium; total 82374 Carbon dioxide (bicarbonate) 82435 Chloride; blood 82465 Cholesterol, serum or whole blood, total 82550 Creatine kinase (CK), (CPK); total 82565 Creatinine; blood 82947 Glucose; quantitative 82977 Glutamyltransferase, gamma (GGT) 83615 Lactate dehydrogenase (LD), (LDH) 84075 Phosphatase, alkaline 84100 Phosphorus, inorganic (phosphate) 84132 Potassium; serum, plasma or whole blood 84155 Protein, total, except refractometry 84295 Sodium; serum, plasma or whole blood 84450 Transferase; aspatrate amino (AST) (SGOT) 84460 Transferase; alanine amino (ALT) (SGPT) 84478 Triglycerides 84520 Urea nitrogen; quantitative 84550 Uric acid; blood (b) Panel tests are reimbursed according to the following schedule. ATP02 Auto Test Panel Pricing Code, 1-2 Tests ATP03 Auto Test Panel Pricing Code, 3 Tests ATP04 Auto Test Panel Pricing Code, 4 Tests ATP05 Auto Test Panel Pricing Code, 5 Tests ATP06 Auto Test Panel Pricing Code, 6 Tests ATP07 Auto Test Panel Pricing Code, 7 Tests ATP08 Auto Test Panel Pricing Code, 8 Tests ATP09 Auto Test Panel Pricing Code, 9 Tests ATP10 Auto Test Panel Pricing Code, 10 Tests ATP11 Auto Test Panel Pricing Code, 11 Tests ATP12 Auto Test Panel Pricing Code, 12 Tests ATP13 Auto Test Panel Pricing Code, 13 Tests ATP14 Auto Test Panel Pricing Code, 14 Tests ATP15 Auto Test Panel Pricing Code, 15 Tests ATP16 Auto Test Panel Pricing Code, 16 Tests ATP17 Auto Test Panel Pricing Code, 17 Tests ATP18 Auto Test Panel Pricing Code, 18 Tests ATP19 Auto Test Panel Pricing Code, 19 Tests ATP20 Auto Test Panel Pricing Code, 20 Tests ATP21 Auto Test Panel Pricing Code, 21 Tests ATP22 Auto Test Panel Pricing Code, 22 Tests ATP23 Auto Test Panel Pricing Code, 23 or more Tests