(1) The medicaid agency pays providers for laboratory services only when:

(a) The provider is certified according to Title XVII of the Social Security Act (medicare), if required; and

(b) The provider has a clinical laboratory improvement amendment (CLIA) certificate and identification number.

(2) The agency includes a handling, packaging, and mailing fee in the reimbursement for lab tests and does not reimburse these separately.

(3) The agency pays for one blood drawing fee per client, per day. The agency allows additional reimbursement for an independent laboratory when it goes to a nursing facility or a private home to obtain a specimen.

(4) The agency pays for only one catheterization for collection of a urine specimen per client, per day.

(5) The agency pays for automated multichannel tests done alone or as a group, as follows:

(a) The provider must bill a panel if all individual tests are performed. If not all tests are performed, the provider must bill individual tests.

(b) If the provider bills one automated multichannel test, the agency reimburses the test at the individual procedure code rate, or the internal code maximum allowable fee, whichever is lower.

(c) Tests may be performed in a facility that owns or leases automated multichannel testing equipment. The facility may be any of the following:

(i) A clinic;

(ii) A hospital laboratory;

(iii) An independent laboratory; or

(iv) A physician's office.

(6) The agency allows a STAT fee in addition to the maximum allowable fee when a laboratory procedure is performed STAT.

(a) The agency pays for STAT charges for only those procedures identified by the clinical laboratory advisory council as appropriate to be performed STAT.

(b) Tests generated in the emergency room do not automatically justify a STAT order, the physician must specifically order the tests as STAT.

(7) The agency pays for drug screen charges only when medically necessary and when ordered by a physician as part of a total medical evaluation.

(8) The agency does not pay for drug screens for clients in the division of behavioral health and recovery (DBHR) within the department of social and health services (DSHS)-contracted methadone treatment programs. These are reimbursed through a contract issued by DBHR DSHS.

(9) The agency does not pay for drug screens to monitor for program compliance in either a residential or outpatient drug or alcohol treatment program.

(10) The agency may require a drug or alcohol screen in order to determine a client's suitability for a specific test.

(11) An independent laboratory must bill the agency directly. The agency does not pay a medical practitioner for services referred to or performed by an independent laboratory.

PDFWAC 182-531-0800

Laboratory and pathology physician-related services.