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THIS
PAGE PRESENTS THE MEDICARE RULES AND LINKS TO OTHER SPECIFIC RULINGS ON MEDICARE BLOOD
TESTING REIMBURSEMENT AND SERVICES. |
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MEDICARE
RULES CHANGE OFTEN. CALL MEDICARE
FOR THE VERY LATEST AND MOST ACCURATE INFORMATION.
MEDICARE - ABN Notice Sample
MEDICARE - Blood Test
Reimbursement and Coverage
MEDICARE - Blood Transfusion Reimbursement and Coverage
BloodBook.com provides on this page, as a
service to our visitors, Medicare reimbursement information pertaining to Blood testing
and some other limited Blood services. Medicare and Medicaid will pay for Blood testing,
therefore, it is certain that this is an important topic. We would like to make this a
more comprehensive presentation, however, the Medicare rulings change often. These changes
affect the reimbursement schedules and differ substantially by state, county, date,
eligibility and qualification requirements. You must know the rules and follow the
rules if you expect Medicare to pay your bills.
Before you commit to anything, be certain as
always, to check with Medicare at the numbers that we
have provided below.
Under the Social Security Act which
established the Medicare insurance program, only Blood testing necessary for treatment or
diagnosis of illness or injury will be reimbursed. Medicare will not pay for checkups or
most Blood screening tests. Blood testing laboratories have been assigned the
responsibility of certifying that the Blood testing that they perform is in compliance
with current Medicare guidelines.
In accordance with those Medicare
requirements, your chosen Blood testing laboratory will probably require most of the
following documentation before the Blood procedure or test will be performed:
Identification of the provider.....
To be certain of reimbursement, the chosen Blood testing laboratory must be able to
identify a qualified provider as defined by Medicare.
There must be a reason for the Blood
test or procedure.....
The provider must complete some required paperwork, fill out the check boxes on a
"requisition," to document the reason for ordering the Blood testing.
Blood screening tests.....
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Title XVIII of the
Social Security Act, section 1862(a)(7) excludes routine physical checkups (including
Blood testing performed in the absence of signs or symptoms) from the Medicare program.
Screening is defined as diagnostic procedures performed in the absence of signs or
symptoms. Screening is often performed based on patient age and/or family
history. While BloodBook.com recommends such examinations and tests as good medical
practice, they are not covered under Medicare. |
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The diagnosis code
indicated on the claim should reflect the reason for performing the requested Blood
laboratory test. |
Limited coverage Blood tests.....
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The Health Care
Finance Administration (HCFA) requires Medicare carriers to establish policies to ensure
the medical necessity of services being paid for by the Medicare program. Carriers in
your local area have the authority to establish a list of Blood tests and test procedures
which may require medical documentation in order for reimbursement to take place. Carriers
will then only approve payment for those particular test procedures when they have
determined them to be medically necessary for the patient. As a result, a claim submitted
without a diagnosis code that indicates medical necessity based upon the local carriers'
policies, will result in denial of payment for those services. You will then have to pay
for these Blood tests out of your own pocket. |
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Payment for
limited coverage tests will be denied unless the claim is accompanied by that appropriate
diagnostic code. The Medicare program will only allow the laboratory to bill the patient
for denied services if an Advance Beneficiary
Notice is completed, the appropriate places checked and signed by the patient, and
forwarded to the Blood testing laboratory. |
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If your chosen
Blood testing laboratory does not receive an acceptable diagnosis on the requisition form,
or a signed Advance Beneficiary Notice,
the office account of your physician may be charged for those denied services and your
failure to provide the appropriate information will be documented. |
Advance Beneficiary Notice
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The Health Care
Finance Administration (HCFA) requires that physicians' offices have a patient sign an Advance Beneficiary Notice Form when a
patient has a Blood screening test performed by a Blood testing laboratory. That Advance
Beneficiary Notice should be submitted to the Blood test laboratory with the Blood test
request form. |
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The Advance
Beneficiary Notice is intended to inform the patient that Medicare will not pay for
services that Medicare determines to be not reasonable and necessary under Section
1862(a)(1) of the Medicare
Law. If Medicare determines that a particular service, although it would otherwise be
covered, is not reasonable and necessary under the Medicare program standards, Medicare
will deny payment for that service. Thus, payment for those screening tests
becomes the responsibility of the patient. You will then have to pay for these Blood tests
out of your own pocket.
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 Medicare
Advance Beneficiary Notice Form
Medicare Blood Transfusion Information
Information on the Advance
Beneficiary Notice Quick Reference Guide is available from the HCFA web site HERE.
For
More Information.....
Call 1-800-MEDICARE (1-800-633-4227) 24
hours
Call 1-877-486-2048 for hearing and speech
impaired
Thank you for
visiting BloodBook.com. |
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