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Pass-through Billing/CLIA Requirements/Reimbursement Policy - Chapter 9, 2020 UnitedHealthcare Administrative Guide

Pass-through Billing / CLIA Requirements / Reimbursement Policy

If you are a physician, practitioner, or medical group, you may only bill for services that you or your staff perform. Pass-through billing is not permitted and may not be billed to our members.

We only reimburse for laboratory services that you are certified to perform through the Federal Clinical Laboratory Improvement Amendments (CLIA). You must not bill our members for any laboratory services for which you lack the applicable CLIA certification.

In-Office Laboratory Tests and CLIA Waived Tests

Limit your laboratory tests done in your office to only those urgently needed. As defined by CLIA, waived tests are simple tests with a low risk for an incorrect result. Sites that perform only waived testing must have a CLIA certificate and follow the manufacturer’s instructions; other CLIA requirements do not apply to these sites. There is a list of approved in-office tests. You must make sure the test is on the CLIA Waived Test List.

All other laboratory tests require a referral to a participating or capitated laboratory. You can find a list of approved codes on CMS.gov > Regulations & Guidance > Legislation >  Clinical Laboratory Improvement Amendments. Participating laboratories are listed on UHCprovider.com.

Note: Some plans are capitated for laboratory services. The capitated laboratory care provider must be used to perform services not allowed in the care provider’s office. In addition, care provider offices granted a CLIA Certificate of Waiver, may conduct a limited number of tests in- house. Tests that may conduct under a certificate of  waiver must meet the descriptive criteria specified on CMS.gov > Regulations & Guidance > Legislation > Clinical Laboratory Improvement Amendments. We will only reimburse laboratory services if in compliance with state and federal regulatory guidelines to include CLIA.

Claim payment is subject to our payment policies and medical policies, which are available online on UHCprovider.com/policies or upon request to your Network Management contact.