THIS PAGE PRESENTS THE MEDICARE RULES AND LINKS TO OTHER SPECIFIC RULINGS ON MEDICARE BLOOD TESTING REIMBURSEMENT AND SERVICES.	TO HOME PAGE
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MEDICARE - ABN Notice Sample
MEDICARE - Blood Test Reimbursement and Coverage
MEDICARE - Blood Transfusion Reimbursement and Coverage

BloodBook.com provides on this page, as a service to our visitors, Medicare reimbursement information pertaining to Blood testing and some other limited Blood services. Medicare and Medicaid will pay for Blood testing, therefore, it is certain that this is an important topic. We would like to make this a more comprehensive presentation, however, the Medicare rulings change often. These changes affect the reimbursement schedules and differ substantially by state, county, date, eligibility and qualification requirements. You must know the rules and follow the rules if you expect Medicare to pay your bills.

Before you commit to anything, be certain as always, to check with Medicare at the numbers that we have provided below.

Under the Social Security Act which established the Medicare insurance program, only Blood testing necessary for treatment or diagnosis of illness or injury will be reimbursed. Medicare will not pay for checkups or most Blood screening tests. Blood testing laboratories have been assigned the responsibility of certifying that the Blood testing that they perform is in compliance with current Medicare guidelines.

In accordance with those Medicare requirements, your chosen Blood testing laboratory will probably require most of the following documentation before the Blood procedure or test will be performed:

Identification of the provider.....
To be certain of reimbursement, the chosen Blood testing laboratory must be able to identify a qualified provider as defined by Medicare. 

There must be a reason for the Blood test or procedure.....
The provider must complete some required paperwork, fill out the check boxes on a "requisition," to document the reason for ordering the Blood testing.

Blood screening tests..... 

Title XVIII of the Social Security Act, section 1862(a)(7) excludes routine physical checkups (including Blood testing performed in the absence of signs or symptoms) from the Medicare program. Screening is defined as diagnostic procedures performed in the absence of signs or symptoms. Screening is often performed based on patient age and/or family history. While BloodBook.com recommends such examinations and tests as good medical practice, they are not covered under Medicare.

The diagnosis code indicated on the claim should reflect the reason for performing the requested Blood laboratory test.

Limited coverage Blood tests.....

	The Health Care Finance Administration (HCFA) requires Medicare carriers to establish policies to ensure the medical necessity of services being paid for by the Medicare program. Carriers in your local area have the authority to establish a list of Blood tests and test procedures which may require medical documentation in order for reimbursement to take place. Carriers will then only approve payment for those particular test procedures when they have determined them to be medically necessary for the patient. As a result, a claim submitted without a diagnosis code that indicates medical necessity based upon the local carriers' policies, will result in denial of payment for those services. You will then have to pay for these Blood tests out of your own pocket.
	Payment for limited coverage tests will be denied unless the claim is accompanied by that appropriate diagnostic code. The Medicare program will only allow the laboratory to bill the patient for denied services if an Advance Beneficiary Notice is completed, the appropriate places checked and signed by the patient, and forwarded to the Blood testing laboratory.
	If your chosen Blood testing laboratory does not receive an acceptable diagnosis on the requisition form, or a signed Advance Beneficiary Notice, the office account of your physician may be charged for those denied services and your failure to provide the appropriate information will be documented.

Advance Beneficiary Notice

The Health Care Finance Administration (HCFA) requires that physicians' offices have a patient sign an Advance Beneficiary Notice Form when a patient has a Blood screening test performed by a Blood testing laboratory. That Advance Beneficiary Notice should be submitted to the Blood test laboratory with the Blood test request form.

The Advance Beneficiary Notice is intended to inform the patient that Medicare will not pay for services that Medicare determines to be not reasonable and necessary under Section 1862(a)(1) of the Medicare Law. If Medicare determines that a particular service, although it would otherwise be covered, is not reasonable and necessary under the Medicare program standards, Medicare will deny payment for that service. Thus, payment for those screening  tests becomes the responsibility of the patient. You will then have to pay for these Blood tests out of your own pocket.

Medicare Advance Beneficiary Notice Form

Medicare Blood Transfusion Information

Information on the Advance Beneficiary Notice Quick Reference Guide is available from the HCFA web site HERE.

For More Information.....

Call 1-800-MEDICARE (1-800-633-4227)  24 hours

Call 1-877-486-2048 for hearing and speech impaired 

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   last updated 03/10/2013   bloodbook.com