Laboratory Services: Service Limitations

(A) The MassHealth agency does not pay a UCC for services listed as non-covered services or for which payment limits apply in accordance with the MassHealth Independent Clinical Laboratory Manual at 130 CMR 401.000: Independent Clinical Laboratory. (B) The MassHealth agency does not pay a UCC 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). (C) The MassHealth agency does not pay a UCC for the professional component of a clinical laboratory service. The MassHealth agency will pay a UCC for the professional component of an anatomical service, as provided in Subchapter 6 of the Urgent Care Clinic Manual (for example, bone marrow analysis or analysis of a surgical specimen). (D) In no event may a UCC bill or be paid separately for each of the tests included in a profile or panel test (as defined herein) when a profile or panel test has either been performed by that UCC or requested by an authorized person. 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. (1) The group of tests is designated as a profile or panel by the UCC performing the tests. (2) The group of tests is performed by the UCC at a usual and customary fee that is lower than the sum of that UCC's usual and customary fees for the individual tests in that group. (E) The MassHealth agency does not pay for tests performed for forensic purposes or any purpose other than those described in 130 CMR 433.438: Clinical Laboratory Services: Introduction, including but not limited to (1) tests performed to establish paternity; (2) tests performed pursuant to, or in compliance with, a court order (for example, monitoring for drugs of abuse); and (3) post-mortem examinations. (F) Some services listed in Subchapter 6 of the Urgent Care Clinic 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 will be determined by the MassHealth agency based on the designation of the test as entered on the claim form. (G) A UCC may not bill for a visit when a member is being seen for laboratory services only.