Payment: Laboratory Services

(A) Covered Services. The MassHealth agency pays for laboratory services listed in Subchapter 6 of the Family Planning Agency Manual that are performed either at the agency or at an outside laboratory as a result of specimen referral. For tests performed at an outside laboratory, the MassHealth agency pays according to the laboratory's charge to the agency or the laboratory fee schedule amount, whichever amount is less. (B) Noncovered Services. The MassHealth agency does not pay separately for routine specimen collection and preparation for the purpose of clinical laboratory analysis (for example, venipunctures; urine, fecal, and sputum samples; Pap smears; cultures; and swabbing and scraping for removal of tissue). The MassHealth agency does not pay for laboratory tests associated with male or female infertility or such calculations as red blood cell indices, A/G ratio, creatinine clearance, and those ratios calculated as part of a profile. (C) Profile or Panel Tests. (1) A profile or panel test is defined as 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 family planning agency performing the tests. (b) The group of tests is performed by the agency at a usual and customary fee that is lower than the sum of that agency's usual and customary fees for the individual tests in that group. (2) In no event may a family planning agency 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 agency or requested by an authorized person. (D) Individual Consideration. Some services listed in Subchapter 6 of the Family Planning Agency Manual are designated "I.C.," an abbreviation for individual consideration. This means that a specific fee could not be established. The payment for an I.C. service is determined by the MassHealth agency’s professional advisors based on the name of the test entered on the claim form. MassHealth Subchapter Number and Title 4. Program Regulations Page Family Planning Agency Manual Transmittal Letter Date