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As a reminder, Independence requires you to direct
members and/or their lab specimens to a participating
outpatient laboratory provider, with the following
exceptions:
- in an emergency;
- as otherwise described in the applicable Benefit
Program Requirements;
- as otherwise required by law.
Please note the following information specific to various
types of benefits plans:
- For HMO/POS members. 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 can?t perform, call Customer
Service at 1-800-ASK-BLUE, as preapproval is
required to issue a referral to a laboratory other than
the member?s capitated laboratory.
- For PPO members. 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 nonparticipating
laboratory, but they will pay the out-of-network level
of cost-sharing (copayment, coinsurance, deductible)
and will be subject to provider balance billing. In the
unusual circumstance that specific services are not
available through a participating laboratory, providers
must call Customer Service at 1-800-ASK-BLUE to
obtain preapproval.
Contractual obligation to use
participating providers
In accordance with your Independence Provider
Agreement, except in an emergency, a participating
provider should refer members only to participating
providers for covered services. This includes, but is
not limited to, ancillary services such as laboratory and
radiology, unless the provider has obtained preapproval
from Independence for the use of a nonparticipating
laboratory.
Noncompliance may result in financial
and other implications for your practice
When applicable under the terms of your Independence
Provider Agreement, if a provider continues to
direct members and/or their lab specimens to a
nonparticipating laboratory and does not obtain
preapproval from Independence, the ordering provider
is required to hold the member harmless.
The ordering provider will be responsible for any
and all costs to the member and shall reimburse the
member for such costs or be subject to claims offset by
Independence for such costs. In addition, further
non-compliance may result in immediate termination of
your Independence Provider Agreement.
Exception to the use of nonparticipating
providers permitted under the terms of
your agreement
If a provider (1) refers a member to a nonparticipating
laboratory for non-emergent services without obtaining
preapproval from Independence to do so; (2) sends a
member?s lab specimen to a nonparticipating laboratory
without preapproval; or (3) provides or orders noncovered
services for a member, the provider must inform
the member in advance, in writing, of the following:
- a list of the services to be provided;
- that Independence will not pay for or be liable for the
listed services;
- that the member will be financially responsible for
such services.
Member Consent for Financial
Responsibility for Unreferred/Non-Covered Services
Form
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
Independence.
Note: Members who have out-of-network benefits
(e.g., PPO) may choose to use a nonparticipating
laboratory for a medically necessary service, but they
may have greater out-of-pocket costs associated with
that service. In addition, the member will be financially
responsible for the entire cost of any service that is
non-covered (e.g., experimental/investigational).
If you have any questions related to the referral process
for laboratory services, please contact your Network
Coordinator.
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