BCBSOK Documentation Guidelines – Laboratory Audit/Review

December 11, 2017

To assist in prompt payment of claims and to ensure payment integrity, Blue Cross and Blue Shield of Oklahoma (BCBSOK) may request medical record documentation in order to determine if the laboratory services billed are appropriately documented in the patient’s medical records.  For BCBSOK to consider services submitted for reimbursement, there must be sufficient documentation in the provider's or hospital's medical records to verify the services performed were appropriately documented, medically necessary and required the level of care billed. If there is insufficient, incomplete or illegible documentation, the services submitted for reimbursement will be denied.  Additionally, claims that have already been adjudicated by BCBSOK are subject to recovery if documentation submitted does not support the services billed.

For every laboratory claim submitted to BCBSOK, the provider should have valid laboratory medical records documenting the services ordered and the results of the services performed on file. Laboratory medical records consist of a signed valid requisition and complete results of the tests performed. A valid requisition is one received from the patient’s treating physician or qualified health care provider (i.e. the provider treating the patient and who will use the test results in the management of the patient’s specific medical problem).  Records should be complete, legible and include the following:

A valid requisition should contain the following:

  • Patient identification
  • Complete ordering provider identification (minimum full name and NPI#)
  • Signature of ordering physician (must be legible) (“Signature on File”, Signature Stamp, or photocopies of signature are not acceptable)
  • Facility and location where sample collected is relevant (State, office, home, hospital, Residential Treatment Center (RTC))
  • Type of sample (e.g. blood, serum, urine, oral swab)
  • Date and time collected
  • Date and time received in the lab
  • Identity of individual who collected sample
  • For urine testing, a temperature at time of collection may be relevant and aid in validity
  • ICD-10-CM diagnosis codes received from ordering provider (specificity required)
  • Identify specific tests ordered
  • For drug testing, a current medication list may be relevant and aid in supporting medical necessity
  • For drug testing Point of Care (POC) test results may be relevant and aid in supporting medical necessity

Additionally, lab results should contain the following information:

  • Complete identification of performing entity (name, address, CLIA #)
  • Identity of Patient (full name, DOB)
  • Identity of ordering provider (name, NPI)
  • Identity of facility if applicable
  • Date sample collected
  • Date sample received in lab
  • Date test results reported
  • Complete test results including validity testing if performed
  • Type of sample (e.g. blood, serum, urine, oral swab)

BCBSOK may request records from an ordering provider to substantiate and provide supporting information during a laboratory claim audit/review. However, it should be noted that the burden of proof remains with the billing provider to be able to provide the required documentation to substantiate the services billed are appropriately documented and are medically necessary. If a medical record request is sent to the provider billing the laboratory services, they must supply the required documentation. Insufficient or a lack of supporting documentation will result in denial of the laboratory services billed.

It should be noted that Medicare auditors also require a billing provider to assume responsibility for obtaining supporting documentation as needed from a referring physician’s office. For more information, see the Medicare Program Integrity Manual PDF Document on the Centers for Medicare & Medicaid Services (CMS) website.

The ordering provider’s medical record must support the medical necessity for each service ordered. The record must be specific to an individual patient and not consist of “standing”, “routine”, “custom panels” or “orders per protocol”. Such “one size fits all” ordering is not appropriate and does not support billing of the laboratory services.

Familiarity with BCBSOK medical policies regarding laboratory testing may prevent unexpected claim denials. Orders and documentation as described above do not ensure reimbursement.  Medical policies, benefits, eligibility and medical record documentation are the additional determining factors for reimbursement. BCBSOK medical policies can be found by visiting the Standards and Requirements section of our website at Individual benefit/coverage information may be found by contacting the customer service number on the back of the member’s insurance card or utilizing your preferred web vendor for an online verification of benefits.

Providers ordering or performing drug testing should carefully review BCBSOK Medical policy # MED207.154. Medical policies are updated regularly so visit this site often for the most up-to-date medical policy information. 

Services that do not meet BCBSOK documentation and/or medical necessity requirements will not be eligible for reimbursement. In addition to BCBSOK, it is useful to recall that Medicare will only pay for tests that are medically reasonable and necessary based on the clinical condition of each individual patient.

Laboratories also should be mindful of requests for testing received from in-patient and intensive out-patient behavioral health facilities as laboratory services are included in per diem rates paid to the entities and should not be “unbundled” and submitted for separate claim reimbursement.  In those instances, separate reimbursement for laboratory services may be denied or disallowed as payment is included in the facility’s per diem payment.

Independent laboratory claims should be submitted to the state where the sample was obtained regardless of where the testing facility resides.

As a reminder BCBSOK does not allow pass through billing or under arrangement billing.  If you have any questions, please contact your Provider Network Representative.