Claims for individual lab tests and complete lab panel codes are processed the same as other individual services. If a panel code is billed, each billed code will be processed using the eligible charge for that code (this differs from Medicare-based plans described in the appropriate subsection). Processing of an individual test or individual panel is shown below:
Individual Laboratory Tests
| Code Billed | Code Used to Process | Code Reported | Basis for Payment |
|---|---|---|---|
| 80074 | 80074 | 80074 | Payment is based on HMSA's eligible charge for 80074. |
However, if all components of an organ- or disease-oriented panel are performed but are billed separately, the codes will be processed and payment will be made using the eligible charge for the panel code. Each billed code will be reported to the provider as billed, and the eligible charge for the panel code will be reported on the first panel code line.
Organ- or Disease-oriented Lab Panels
| Codes Billed | Code Used to Process | Codes Reported | Basis for Payment |
|---|---|---|---|
82465 83718 84478 | 80061 | 82465 83718 84478 | Payment is based on HMSA's eligible charge for 80061 ($23.10). If payment is made at 100 percent of the eligible charge, the payment amounts will appear on the RTP as in the example here: 82465 - $23.10 83718 - $0.00 84478 - $0.00 |
Note: In this example, each processed line (individual test) will also include a message explaining that it was processed based on the panel code.
The payment amounts shown in the examples in this section are for illustration purposes only and may vary depending on any negotiated arrangements between the provider and HMSA. The percent of eligible charge that is paid also may vary depending on the member's plan benefits.
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform |