New Laboratory Benefit Management Program: Revised Effective Date for Some Policies

October 26, 2022

Our new program with Avalon Healthcare Solutions for claims for certain outpatient laboratory services provided to many of our commercial, non-HMO members becomes effective Nov. 1, 2022. 

Previously, we alerted you that Clinical Payment and Coding Policies (CPCPs) related to certain laboratory services, tests, and procedures would be implemented using a phased approach. As of Aug. 1, 2022, some of our Laboratory Benefit Management Program CPCPs listed an effective date of Nov. 1, 2022; other lab CPCPs listed an effective Jan. 1. 2023. 

Please note that all Laboratory Benefit Management Program CPCPs that were previously identified as being effective Jan. 1, 2023, have been updated with a new effective date of Feb. 1, 2023. The effective date in these policies is the only detail that was changed.

Resources and Reminders
Registered Availity® Essentials users have free access to Avalon’s Trial Claim Advice Tool. This tool is available 24/7. It 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.

The Trial Claim Advice Tool doesn’t 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.

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.

This program doesn’t 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.