New Laboratory Program Coming Jan. 1


Sept. 29, 2021

Effective Jan. 1, 2022, Blue Cross and Blue Shield of Texas (BCBSTX) will implement new policies and a new program for claims for certain outpatient laboratory services provided to our Fully Insured commercial members. Our new Laboratory Management Program with Avalon Healthcare Solutions (Avalon) will help members get the right care at the right time and in the right setting. It will also help you better prepare to submit claims which support and reflect high quality, affordable care delivery to our members.

Policy Updates
Watch for new and revised medical and reimbursement policies effective Jan. 1, 2022, related to certain laboratory, services, tests and procedures. You can view both current and pending BCBSTX medical policies and our Clinical Payment and Coding Policies on the provider website.

Affected claims: Our new program includes a review of claims post-service and pre-payment for the following outpatient laboratory claims:

  • Dates-of-service on or after Jan. 1, 2022
  • Performed in an outpatient setting (typically office, hospital outpatient or independent laboratory)

Note: Laboratory services provided in emergency room, hospital observation and hospital inpatient settings are excluded from this program. Member contract benefits and clinical criteria still apply.

New Claim Simulation Tool
You will have access to Avalon’s Trial Claim Advice Tool, which allows providers to input laboratory procedure and diagnosis codes before submitting a claim, to see the potential outcome of your claim. The Trial Claim Advice Tool is a free simulation tool and does not guarantee approval, coverage or reimbursement of services. Responses consider information entered through the tool for the date of service entered and historical claims finalized through the previous business day. Claims not yet finalized won’t be considered.

What you need to do:

For More Information:
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Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX. BCBSTX makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity.