New Laboratory Management Program to Begin Nov. 1, 2022

August 1, 2022

You may have seen the communication about the delayed launch of our new Laboratory Benefit Management program with Avalon Health Solutions. We delayed this launch to continue providing education and clarity to providers about the program.

Effective Nov. 1, 2022, Blue Cross and Blue Shield of Illinois (BCBSIL) will implement its new program with Avalon Healthcare Solutions for claims for certain outpatient laboratory services provided to many of our commercial, non-HMO members.

This program does not apply at this time to government programs or any of our HMO members.

The new program will:

  • Help our members access the right care at the right time and in the right setting
  • Better prepare you to submit claims for covered services reflecting quality, affordable care delivery to our members

See below for key points and provider resources to help you prepare.

Policy Updates
The Clinical Payment and Coding Policies (CPCPs) page on our Provider website was updated on Aug. 1, 2022. On this page, you’ll find a link to view Laboratory Benefit Management Program CPCPs becoming effective on Nov. 1, 2022, related to certain laboratory services, tests, and procedures. Policies will be implemented using a phased approach, and effective dates are indicated on each CPCP.

Affected Claims
Our new program may include:

  • Outpatient laboratory claims with dates of service beginning Nov. 1, 2022 
  • Claims for services performed in an outpatient setting (typically office, hospital outpatient or independent laboratory)

Note: Laboratory services provided in an emergency room, hospital observation or hospital inpatient setting are excluded from this program. Member coverage terms still apply. Additionally, claim edits will not initially apply to the rate at which tests have been ordered or with respect to the age or gender of a patient.

Self-service Trial Claim Advice Tool via Availity® Essentials
Since April 1, 2022, registered Availity users have had free access to Avalon’s Trial Claim Advice Tool, which is available 24/7. This tool allows you to input laboratory procedure and diagnosis codes to better understand the potential outcome of claims. Not registered for Availity? Sign up online today, at no cost.

Note: The Trial Claim Advice Tool does not guarantee approval, coverage, or reimbursement for health care services. Potential claim outcomes provided by Avalon’s Trial Claim Advice Tool consider information entered in the tool for the date of service, claims finalized through the prior business day, and applicable policies and/or guidelines.

For More Information
Continue to watch the News and Updates page for future program updates and training opportunities.

This program does not apply at this time to government programs or any of our HMO members.

Avalon Health Solutions (Avalon) is an independent company that provides claims management services for members with coverage through BCBSIL. 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 BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services regarding third party vendors and the products and services they offer.