Medicare/Government Health Care Programs

UPDATE: The Affordable Care Act requires physicians or other eligible Non-Physician Practitioners (NPPs) to register in the PECOS database to order/refer services for Medicare patients by January 6, 2014. Please click here for important PECOS enrollment information.

Medicare

Genova Diagnostics is a participant in the Medicare program. Genova Diagnostics will file claims directly with Medicare, on behalf of patients, if:

  1. The test is medically necessary and billable to Medicare.
  2. The health care practitioner has a valid National Provider Identifier (NPI). Please note: If the health care practitioner is not authorized to order or refer laboratory services, according to Medicare program guidelines, the patient will be financially responsible for the charges.
  3. A completed requisition form is received with valid ICD-9 diagnosis coding and a copy of the patient's Medicare card.

For tests not considered diagnostic by Medicare, EasyPay Schedule B is recommended. These are indicated as statutorily excluded tests on the Advance Beneficiary Notice (ABN) or by a notice of non-coverage by Medicare included the kit. Medicare patients may choose our EasyPay Schedule B option when:

  1. The test is likely to be denied by Medicare and the patient selects option two on his/her ABN
  2. The test is determined by Medicare as screening or statutorily not covered
  3. If receiving services from a health care practitioner that is not authorized to order or refer laboratory services according to Medicare program guidelines

The Medicare program requires that the patient be given a form called an Advanced Beneficiary Notice (ABN) for certain tests. The ABN is included in applicable test kits and should be reviewed carefully by the patient.

The ABN is mandated by Medicare to:

  1. Advise the patient that the test may not be covered by Medicare (informed consent);
  2. Allow the patient, with informed consent, to authorize the lab to perform the test and to bill Medicare, or to allow the patient to make payment at a discounted price to minimize their out-of-pocket expense and without having a claim filed with Medicare; and
  3. Allow the patient, with informed consent, to acknowledge that if Medicare doesn't cover the claim, then the Medicare beneficiary will be financially responsible for the tests listed on the notice.

The ABN must be obtained prior to sending the test sample/specimen. To be completed properly, the ABN must have the beneficiary's name indicated at the top, must have an option selected with a check or "x", and must be signed and dated by the patient. The ABN must be sent with the requisition and test sample/specimen. Medicare regulations require the covered party to be given a copy of the signed ABN by the practitioner's office.

Medicare Compliance

Genova Diagnostics has taken a proactive role in Medicare Compliance. We fully support federal regulations to enforce financial and professional integrity and to ensure that tests ordered under Medicare reimbursement meet the standards of "medical necessity."

All claims submitted to Medicare for Genova Diagnostics' laboratory services must be for tests that are medically necessary. "Medically necessary" is defined as a test or procedure that is reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member. Consequently, tests performed for screening purposes will not be reimbursed by the Medicare program. Health care practitioners may deem it medically necessary to order a single test or a portion of a test profile.

Medicare Advantage

Medicare Advantage plans will be processed through the EasyPay program. Based on the plan provider, either EasyPay Schedule A or EasyPay Schedule B will be used. Please see EasyPay Schedule B list for Medicare Advantage insurance providers that are eligible for EasyPay Schedule B. For all other Medicare Advantage insurance providers NOT listed on the EasyPay Schedule B list, please see the EasyPay Schedule A guidelines.

Please Note: Some Medicare Advantage plans assign substantial out-of-pocket expenses for Genova's services. Medicare Advantage patients who are covered by a EasyPay Schedule B insurance provider should consider whether they want to receive services from Genova Diagnostics, especially those services that have a likelihood of resulting in substantial out-of-pocket expenses.

Medicaid

Genova Diagnostics only files claims with Medicaid programs in the following states:

  • North Carolina
  • Minnesota
  • Oregon

Health care practitioners must be authorized to order or refer laboratory services according to Medicaid program guidelines.

Medicaid patients may choose our EasyPay Schedule B option if they are receiving testing services in any other state not listed above.

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