Laboratory Services Overview

Outpatient laboratory claims are typically billed on a CMS 1500 claim form using the CPT code for individual tests or a single code for a panel of tests. These services are performed at a hospital or other healthcare facility on an outpatient basis, or through an independent lab.

Payment for laboratory services is HMSA's eligible charge, less any member copayment and/or deductible. Individual lab tests will be unbundled and rebundled when applicable, as described in this section.

Note:

Processing of lab claims for HMSA's Preferred Provider Plans, the State Plan, Federal Plan 87, HMSA Plan for Postal Service Employees, and HMO commercial plans differs from processing of lab claims for Medicare Advantage plans. This section includes billing instructions and claims processing examples for both.

HMSA recognizes the Model Compliance Plan for Clinical Laboratories issued by the U.S. Department of Health & Human Services Office of Inspector General (HHS OIG) as a description of clinical laboratory best practices.

Access the Model Compliance Plan.

Revision History