Capital BlueCross: Outpatient Laboratory Services Claims Processing

Blue Cross Blue Shield Association claims processing for outpatient laboratory services requires all outpatient laboratory claims to be sent to the local plan, which is determined by the location of the physician referring the member for outpatient lab services.

Capital BlueCross customers will not be adversely impacted by the Independence BlueCross (IBC) announcement of Laboratory Corporation of American Holdings (LabCorp) as their primary provider of outpatient laboratory services and Quest Diagnostics no longer participating in the IBC network.

Lab claims directed by referring providers in the five counties in Pennsylvania including Bucks, Chester, Delaware, Montgomery, and Philadelphia will continue to be directed to a contracted plan and be processed as “in network” to prevent disruption to Capital BlueCross customers.

When more than one Blue Cross Blue Shield plan has executed participating provider agreements with regional providers, the determination of the appropriate agreement for claim submission is determined based upon the below criteria:

  • If the referring physician is located within Capital BlueCross’ 21 county licensed region and extending to contiguous counties to include Bucks, Montgomery, and Chester counties, Capital BlueCross would be the local plan for claim submissions utilizing our existing participation agreements with both LabCorp and Quest Diagnostics.
  • For referring physicians located in the counties of Delaware and Philadelphia, Quest continues to participate with a Blue Cross Blue Shield plan for this region providing the continuation of in network processing through the BCBSA rules for Capital BlueCross customers.

Member benefit determinations and levels of copayments and coinsurance are based on the participation status of the laboratory with the local plan as determined above.

Quest Diagnostics continues to be a participating provider either directly with Capital BlueCross or through the guidelines provided by BCBSA in all counties within IBC’s region. A Capital BlueCross provider bulletin reaffirms Quest Diagnostics’ status as a participating laboratory services provider.

DISCLOSURE

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The information provided is for informational purposes only and does not constitute legal advice. The information above contains only a summary of the applicable legal provisions and does not purport to cover every aspect of any particular law, regulation or requirement. Depending on the specific facts of any situation, there may be additional or different requirements. This is to be used only as a guide and not as a definitive description of your compliance obligations.