For HMSA's Medicare-based plans, all laboratory claims are processed the same way, whether for individual tests or for test panels. Medicare bases its payment for lab tests on the aggregate of individual tests, called "Automated Test Panels" or ATP. The total number of tests on a claim is represented by a number following ATP (e.g., ATP03 would be an automated test panel composed of three individual tests; ATP11 would be an automated test panel composed of eleven individual tests). An individual test on a claim is converted to ATP01 (for one test), and the eligible charge for ATP01 is applied, as shown below:
Claims Processing: Individual Laboratory Tests
| Code Billed | Code Used to Process | Code Reported | Basis for Payment |
|---|---|---|---|
| 80074 | ATP01 | 80074 | Payment is based on Medicare's eligible charge for ATP01. |
For HMSA's Medicare-based plans, all laboratory claims are processed the same way, whether for individual tests or for test panels. Medicare bases its payment for lab tests on the aggregate of individual tests, called "Automated Test Panels" or ATP. The total number of tests on a claim is represented by a number following ATP (e.g., ATP03 would be an automated test panel composed of three individual tests; ATP11 would be an automated test panel composed of eleven individual tests). An individual test on a claim is converted to ATP01 (for one test), and the eligible charge for ATP01 is applied, as shown below:
Claims Processing: Individual Laboratory Tests
| Code Billed | Code Used to Process | Code Reported | Basis for Payment |
|---|---|---|---|
| 80074 | ATP01 | 80074 | Payment is based on Medicare's eligible charge for ATP01. |
If multiple tests are billed, either as individual tests or as panel codes, they will be processed according to the eligible charge for the ATP representing the total number of individual tests, as shown below:
Claims Processing: Blood Chemistry Laboratory Tests (No Duplicates)
| Code Billed | Code Used to Process | Code Reported | Basis for Payment |
|---|---|---|---|
80051 (4 tests) 80076 (7 tests) 82565 (1 test) Total: 12 tests | ATP12 | 80051 80076 82565 | Payment is based on Medicare's eligible charge for ATP12. |
In accordance with Medicare's methodology for lab claims processing and HIPAA, HMSA will report the claim on the electronic remittance and Report to Provider by applying payments to the individual codes by the same factor derived by dividing the total eligible charge by the total billed charges for the processed ATP code, as shown below:
Payment and Reporting: Blood Chemistry Laboratory Tests (No Duplicates)
| Codes Billed | Processed Code/EC | Derived Factor | Codes Reported and Eligible Charge Allocated to Each Line |
|---|---|---|---|
80051: $34.45 80076: $37.65 82565: $18.80 Total: $90.90 | ATP12: $12.48 | $12.48 (EC) $90.90 (Billed) = .1373 (factor applied to each billed line to report a proportion of eligible charge on each line) | Payment is based on Medicare's eligible charge for ATP12. If payment is made at 100 percent of the eligible charge, the payment amounts will appear on the RTP with fees allocated to each line, as in the example here: 80051: $4.73 ($34.45 x .1373) 80076: $5.17 ($37.65 x .1373) 82565: $2.58 ($18.80 x .1373) |
Note: In this example, each processed line (individual test) will also include a message explaining that it was processed based on the panel code.
Medicare's pricing methodology will deny duplicate tests, even if they are performed as part of separate panels, or if they are individual tests that were also included in a panel. If duplicate tests are billed, the ATP will be reduced by the number of duplicates. The example below shows the reduction in the ATP because a duplicate test was denied:
Claims Processing: Blood Chemistry Laboratory Tests (With Duplicates)
| Codes Billed | Code Used to Process | Codes Reported | Basis for Payment |
|---|---|---|---|
80051 (4 tests) 80076 (7 tests) 84132 (1 test) Total: 12 tests | ATP11 (one duplicate) | 80051 80076 84321 | Payment is based on Medicare's eligible charge for ATP11; because it is a duplicate, 84132 is not counted. |
Again, in accordance with Medicare's methodology for lab claims processing and HIPAA, HMSA will report the claim on the electronic remittance and Report to Provider by applying payments to the individual paid codes by the same factor derived by dividing the total eligible charge by the total billed charges for the processed ATP code, as shown below:
Payment and Reporting: Blood Chemistry Laboratory Tests (With Duplicates)
| Codes Billed | Processed Code/EC | Derived Factor | Codes Reported and Eligible Charge Allocated to Each Line |
|---|---|---|---|
80051: $34.45 80076: $37.65 82565: $ 6.95 Total: $79.05 less ($ 6.95) = $72.10 (because 82565 is included in 80051, it is denied as a duplicate) | ATP11: $12.21 | $12.21 (EC) $72.10 (Billed) = .1693 (factor applied to each billed line to report a proportion of eligible charge per paid line) | Payment is based on Medicare's eligible charge for ATP12. If payment is made at 100 percent of the eligible charge, the payment amounts will appear on the RTP with fees allocated to each line, as in the example here: 80051: $5.83 ($34.45 x .1693) 80076: $6.38 ($37.65 x .1693) 82565: $0.00 ($ 6.95 x .0000) |
Note: In this example, each processed line (individual test) also will include a message explaining that it was processed based on the panel code.
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform |