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HomeMy WebLinkAboutMH-210 Reimbursement for Laboratory Procedures1 FRANKLIN/FULTON COUNTY MENTAL HEALTH/INTELLECTUAL & DEVELOPMENTAL DISABILITIES/EARLY INTERVENTION 425 Franklin Farm Lane Chambersburg, PA 17202 (717) 264-5387 MH/IDD/EI PROCEDURE STATEMENT PROCEDURE SUBJECT: Reimbursement for Laboratory Procedures PROCEDURE NUMBER: MH-210 Effective Date: January 1, 2016 Date Revised: June 20, 2018 Reference: 55 PA Code Chapter 4220, Reimbursement for Medication, August 1985 PURPOSE: This statement establishes policies and procedures for prescribing and payment of laboratory procedures used solely for the treatment of diagnosed mental illness, for individuals funded by the MH/IDD/EI Program. PROCEDURE: Prescription:  A laboratory procedure needed to monitor the dosages and organ functions must be: prescribed by a Practitioner licensed by the State to; and be specifically for mental health diagnosis under treatment for it to be reimbursed by the MH/IDD/EI Program. The MH/IDD/EI Administrator can approve exceptions with a clear clinical rationale from the prescriber. Requests for exceptions are to be submitted in writing to the MH/IDD/EI Administrator.  All third party revenues must be exhausted before MH/IDD/EI funds can be used for laboratory procedure reimbursement.  All laboratory procedures must be licensed by the Department of Health to receive reimbursement. Limitations: A listing of MH/IDD/EI approved reimbursable laboratory procedures is attached. 2 Individuals Eligible to Receive MH/IDD/EI Laboratory Services:  Individuals must not be eligible for any other insurance plan/reimbursement, full or partial.  Any individual who has a liability abatement and/or diagnostic abatement by the MH/IDD/EI Administrator. (A diagnostic liability abatement may be requested by a clinician/ psychiatrist/ physician in writing to the MH/IDD/EI Administrator, if it is determined that the individual should not be held responsible for his/her liability prior to getting laboratory procedures. See MHIDD-302 Individual Financial Liability, for more information.)  Eligible individuals will have an order for laboratory procedures identifying Franklin/Fulton MH/IDD/EI as payer. A laboratory procedure completed for someone without a liability will not be reimbursed without a prior authorization letter. MH/IDD/EI Responsibilities:  It is the responsibility of the Service Access and Management or True North Wellness Services Case Manager to see that all third party payees have been exhausted and proof is in the individual’s case file, in the form of a letter from his/her insurance company or other proof before authorizing for MH/IDD/EI paid laboratory procedures. For the Prescribing Psychiatrist or Physician:  For any individual eligible for MH/IDD/EI payment of laboratory procedures, the physician may prescribe any laboratory procedure, but only those on the attached laboratory procedures will be paid unless an exception is made. If there are any questions regarding an individual’s eligibility, the provider should contact the MH/IDD/EI office prior to prescribing a laboratory procedure. For the Laboratory:  MH/IDD/EI will not pay for any laboratory procedure that is not listed on the attached laboratory procedures.  In addition, per Center for Medicare and Medicaid Services (CMS) regulation as documented in MA Bulletin 99-11-05, Provider Screening of Employees and Contractors for Exclusion from Participation in Federal Health Care Programs and the Effect of Exclusion on Participation, we are unable to make payment to any provider who has not followed the bulletin. ATTACHMENT: MH/IDD/EI Laboratory Procedures 3 FRANKLIN/FULTON MH/IDD/EI LABORATORY PROCEDURES The following laboratory procedures will be covered. 80050 Comp metab panel 80061 Lipid Panel 80178 Lithium 80076 Hepatic Function Panel 80104 Drug Screen 11 Panel 80156 Carbamazepine (Tegretol) 80164 Dipropylacetic Acid (Valproic Acid) 82565 Creatinine; Blood 84443 Thyroid stimulating hormone 84450 Transferase; Asparatate Amino 84460 Transferase; Alanine Amino 84520 Urea Nitrogen Quantitative 85025 CBC Automated w/auto diff