Laboratory Services: Payment

(A) Maximum Allowable Fees. The MassHealth agency pays an acute or a private chronic disease and rehabilitation hospital outpatient department for laboratory services in accordance with the rates set forth in regulations at 101 CMR 320.00: Rates for Clinical Laboratory Services, and 101 CMR 316.00: Surgery and Anesthesia Services, as applicable, subject to the conditions, exclusions, and limitations set forth in 130 CMR 410.000. (B) Usual and Customary Fee. The term usual and customary in the hospital outpatient department laboratory context means the lowest fee charged by a hospital outpatient department laboratory for any laboratory service (including both individual and profile tests) specified in the hospital outpatient department's charge book or by such hospital, with the exception of a fee offered for a bulk purchase. (A bulk purchase is a single purchase of a laboratory service (one or more tests) to be uniformly and concurrently performed on a minimum of 40 specimens of the same type. A single purchase of various, non-uniform laboratory services, such as by a physician, is not considered a bulk purchase, regardless of the number of specimens presented by such a purchaser to the hospital outpatient department laboratory.) (C) Profile or Panel Tests. (1) A profile or panel test is any group of tests, whether performed manually, automatedly, or semiautomatedly, that is ordered for a specified member on a specified day and has at least one of the following characteristics. (a) The group of tests is designated as a profile or panel by the hospital outpatient department laboratory performing the tests. (b) The group of tests is performed by the hospital outpatient department laboratory at a usual and customary fee that is lower than the sum of that hospital outpatient department laboratory's usual and customary fees for the individual tests in that group. (2) In no event shall a hospital outpatient department laboratory bill or be paid separately for each of the tests included in a profile test when a profile test has either been performed by that hospital outpatient department laboratory or requested by an authorized person.