Lab testing is highly complex and constantly evolving. Starting March 1, 2023, EmblemHealth and ConnectiCare will begin a new collaboration with Avalon Healthcare Solutions (Avalon) to implement a Laboratory Benefit Management (LBM) program. This will help us stay current and process laboratory claims with greater accuracy and consistency.
Using their expertise in laboratory services, Avalon will review laboratory services performed in office, hospital outpatient, and independent laboratory settings reported on claims (post-service and pre-payment) for adherence and consistency with our laboratory policies and guidelines, as well as industry standardized rules. Avalon will provide routine testing management services with automated review of high-volume, low-cost laboratory tests.
In support of this program, we will be introducing a new payment integrity policy as of March 1, 2023, as well as new and revised reimbursement policies and guidelines.
The new Laboratory Benefit Management Payment Integrity Policy details the program components, including impacted laboratory services, tests, and procedures. It also includes a section of anticipated frequently asked questions (FAQs).
To provide transparency regarding this program and the review standards that will be used, these reimbursement policies and guidelines will be added to the following sections of our websites in the coming weeks for your review:
- EmblemHealth: Reimbursement Policies
- ConnectiCare: Reimbursement Policies