Physicians/Specialists
Facilities/Hospitals
Ancillary
Publication Date: 
2019-11-20

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is expanding our Laboratory Benefit Management Program with Avalon Healthcare Solutions (Avalon) to include enhanced, post-service consistency reviews of laboratory services.

Beginning in late November, Blue Cross NC will use Avalon’s post-service automated policy enforcement (APEA) technology to evaluate historical claims reporting the following:

  • Office services
  • Hospital outpatient services
  • Independent laboratory services

Key Points

  • APEA combines clinical research with technology and is designed to help ensure the consistent application of Blue Cross NC's medical policies and guidelines.
  • Using APEA technology, claims reporting laboratory services will be reviewed for compliance and consistency with Blue Cross NC’s medical policies and guidelines, as well as industry-standardized rules including, but not limited to, evaluating services as experimental and/or investigational, meeting medical necessity, appropriateness for patient demographics, and unit allowances.
  • By adding APEA functionality to our Laboratory Benefit Management Program’s post-service review processes, we look to improve quality and reduce costs for our members' laboratory services.

The following frequently-asked questions provide additional details about this expansion and can help answer some of the questions you may have.

What is the APEA tool and what does it do?
APEA is a technology tool designed to enhance the administration of medical coverage policies and guidelines. The APEA technology will help us better ensure compliance with Blue Cross NC’s medical policies and guidelines and apply industry-standardized consistency rules for our members' laboratory services.

How will Blue Cross NC use APEA technology for post-service claims?
When laboratory services are reported on a member's claim, APEA technology will be used to review that member's specific Blue Cross NC claims history and compare their prior laboratory services with those reported on the current claim. This comparison provides us with a more complete understanding of members' past and present laboratory services and helps us ensure the laboratory services reported on new claims are reviewed for compliance and consistency with Blue Cross NC's medical policies, guidelines, and industry-standardized rules.

Does Blue Cross NC already use APEA technology?
Yes. Since April 2019, Blue Cross NC has used APEA technology to review claims reporting laboratory services for adherence with our medical policies and guidelines. (Notice was given in March 2019.) Our current APEA-based reviews consider laboratory services reported on claims for appropriateness with documented medical policies and guidelines, but do not consider members' specific past utilization of laboratory services. In late November, we’ll turn on additional system functionality, which allows for member-specific past utilization of laboratory services to be considered as part of the post-service claims review process.

Will Blue Cross NC's use of APEA technology result in reimbursement denials for some services?
When laboratory services are reported on a member's claim and identified by Blue Cross NC as being non-compliant with our medical policies, guidelines, and/or industry-standardized rules, all or part of the claim's potential reimbursement may be denied.

Please note - claims received after we begin using APEA technology will be processed with historical comparisons of member-specific claims information applied. As a result, claims previously processed and resubmitted to us for secondary reviews and/or provider-requested adjustments (including corrected claims) may adjudicate differently than when initially processed.

Blue Cross NC does not intend to perform a retrospective review of claims already processed between April and September and apply APEA-based historical comparisons to claims reporting laboratory services.

Enhanced reviews through APEA technology apply/do not apply to the following:

  The following are eligible for enhanced reviews through APEA technology: The following are ineligible for enhanced reviews through APEA technology:
Members
  • Members enrolled in Blue Cross NC's commercially-insured and administered products
  • Members enrolled in the State Health Plan
  • Non-Medicare Advantage BlueCard® members
  • Members enrolled in Blue Cross NC's Medicare Advantage products
  • BlueCard members (when enrolled in other Blue Cross and Blue Shield-offered Medicare Advantage products)
  • Members enrolled through the Federal Employees Program
Types of Claims
  • All claims reporting laboratory services (HCFA-1500 and UB) performed in all places of services, except for inpatient and emergency room settings
  • Laboratory services, tests, and procedures provided in an emergency room, hospital observation room, and any inpatient setting
Types of Information
  • Experimental and investigational (procedure is not covered under the member's benefit due to experimental and/or investigational exclusions)
  • Demographics (limitations based on patients' age or gender)
  • Specific unit allowances (maximum allowable units within a defined period of time)
  • Time between procedures (minimum time required before a second procedure is medically necessary)
  • Rendering provider limitations (providers/procedures not permitted in combination)
  • Diagnosis constraints and allowances (procedure and diagnosis required or prohibited combinations)
  • Non-compliance with Blue Cross NC's medical policies (the most up-to-date Blue Cross NC medical policies are available here)
 

Is there a tool available to help providers predictively model how laboratory claims might process when APEA-based compliance and consistency reviews are applied?
Avalon’s "Trial Claims Advice" link is available through Blue e. This functionality allows providers to test codes and review likely scenarios about how laboratory claims might process. The link:

  • Gives providers an estimate of how a member's laboratory codes will probably interact and process, based on the information entered
  • Offers providers access to a tool that's compliant with Blue Cross NC's reimbursement and medical policies

A simple form is also available for online authorization request for genetic testing.

Participating Laboratory List
Avalon manages the exclusive network of independent reference laboratories for our commercially-insured and administered products. Only laboratories contracted with Avalon are eligible to provide in-network laboratory services and receive payments under our members' in-network benefits.

If your health care organization makes referrals for patients' laboratory tests and services, please review the participating laboratory list to find an eligible, in-network laboratory location.