A participating provider should refer members only to participating providers for covered services, except in an emergency.

This includes, but is not limited to, ancillary services such as laboratory and radiology, unless the provider has obtained preapproval from AmeriHealth for the use of a non-participating laboratory. The rules governing lab referrals are outlined in the AmeriHealth Provider Agreement.

Participating providers are required to direct members and/or their lab specimens to a participating outpatient laboratory provider, except:

LabCorp is the exclusive outpatient laboratory provider for AmeriHealth New Jersey members.

• in an emergency.
• as otherwise described in the applicable Benefit Program requirements.
• as otherwise required by law.

Benefit Program requirements

Benefit Program requirements differ by type of plan:

• HMO/POS. All routine laboratory services for HMO/POS members must be referred to their primary care physician's (PCP) capitated laboratory site. In the unusual circumstance that you require a specific test that you believe the PCP's capitated laboratory site cannot perform, call Customer Service at 1-888-YOUR-AH1 (1-888-968-7241) (AmeriHealth New Jersey) or 1-800-275-2583 (AmeriHealth Pennsylvania). Preapproval is required to issue a referral to a laboratory other than the member's capitated laboratory. To confirm a member's capitated laboratory site, refer to the Lab indicator on the front of the member's ID card or use the Eligibility and Benefits Inquiry transaction on the NaviNet^® web portal (NaviNet Open).*  

• PPO. PPO members should use a participating laboratory, such as Laboratory Corporation of America^® Holdings (LabCorp), to maximize their benefits and save on out-of-pocket costs. PPO members may use a non-participating laboratory, but they will pay the out-of-network level of cost-sharing (i.e., copayment, coinsurance, or deductible) and may be subject to provider balance billing, if permitted by applicable law. In the unusual circumstance that specific services are not available through a participating laboratory, providers must call Customer Service at 1-888-YOUR-AH1 (1-888-968-7241) (AmeriHealth New Jersey) or 1-800-275-2583 (AmeriHealth Pennsylvania) to obtain preapproval.

• EPO (AmeriHealth New Jersey only). All routine laboratory services for EPO members must be referred to a participating laboratory. EPO members do not have out-of-network benefits.

Non-compliance may result in financial and other implications for your practice

When applicable under the terms of your AmeriHealth Provider Agreement, if a provider continues to direct members and/or their lab specimens to a non-participating laboratory and does not obtain preapproval from AmeriHealth, the ordering provider is required to hold the member harmless.

The ordering provider will be responsible for all costs to the member and shall reimburse the member for such costs or be subject to claims offset by AmeriHealth for such costs. In addition, further non-compliance may result in a corrective action plan or immediate termination of your AmeriHealth Provider Agreement.

Exception to the use of non-participating providers permitted under the terms of your agreement

The provider must inform the member verbally and in writing in advance of the services if he or she:

• refers a member to a non-participating laboratory for non-emergent services without obtaining preapproval from AmeriHealth to do so; or
• sends a member's lab specimen to a non-participating laboratory without preapproval; or
• provides or orders non-covered services for a member.

In the case of an exception, the provider must tell the member:

• which services will be provided; and
• that AmeriHealth will not pay for or be liable for the listed non-covered services; and
• that the member will be financially responsible for such services.

Providers should also be aware of the coverage status of the tests they order and should notify the member in advance if a service is considered experimental/investigational or is otherwise non-covered by AmeriHealth. The member will be financially responsible for the entire cost of any service that is non-covered (e.g., experimental/investigational).

If a provider does not comply with the requirements as outlined above, the ordering provider is required to hold the member harmless. The ordering provider will be responsible for all costs to the member and shall reimburse the member for such costs or be subject to claims offset by AmeriHealth for such costs.

Using eviCore

To review lab management and policies for eviCore healthcare (eviCore), please read Updated Lab Management Clinical Guidelines.

Learn more

AmeriHealth New Jersey providers with questions about the laboratory referral process can contact their Provider Partnership Associate.

AmeriHealth Pennsylvania providers with questions about the laboratory referral process can email our Provider Network Services team at ahpnsproviderrequests@amerihealth.com.

*If your organization has transitioned to use PEAR Practice Management on the Provider Engagement, Analytics & Reporting (PEAR) portal, you can use the Eligibility & Benefits transaction to view this information. Additional information and self-service training materials are available in the PEAR portal Help Center.