NPL
Compliance Policies
HIPAA
Northern
Plains Laboratory, LLC, is committed to complying with all Health Insurance
Portability and Accountability Act (HIPAA) privacy and security standards. Northern Plains Laboratory has implemented
policies and procedures to ensure compliance with the privacy and security
standards.
Our
employees maintain confidentiality of protected health information (PHI). Northern Plains Laboratory limits the
protected health information (PHI) that is used, disclosed, and requested to
that which is necessary to accomplish the intended purpose.
If
you have questions about NPL’s compliance activities, please contact the
Compliance Officer at 1-800-659-0395.
Medical
Necessity
Only tests that
are medically necessary for the diagnosis or treatment of a Medicare or
Medicaid patient will be reimbursed. The Office of Inspector General takes the
position that when medically unnecessary tests are ordered which result in
false claims to Medicare or Medicaid, the physician may be subject to civil
penalties under the False Claim Act.
The
ordering physician/provider must submit diagnosis information, preferably an
ICD-10 code, for each test ordered. The diagnosis must be consistent with the
diagnosis recorded in the patient’s medical record on the date of service.
Medicare
may not pay for non-FDA approved tests or those considered to be experimental.
Medicare
generally does not pay for screening tests except for certain specifically
approved procedures that have frequency limits.
Advance
Beneficiary Notice of Noncoverage (ABN)
If there is reason to
believe that Medicare will not pay for a test, the patient should be informed
of that fact. The patient should sign a properly completed Advance Beneficiary
Notice of Noncoverage (ABN) to indicate that they have been informed and are
responsible for payment of the test if Medicare denies payment.
National
Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs)
The NCDs for 23 clinical
laboratory tests went into effect November 25, 2003. The NCDs promote
consistency and standardization of medical necessity nationwide. The Medicare
Administrative Contractor (MAC) have LCDs for additional tests that are not
among the NCDs. Both the NCDs and LCDs
specify whether a service is reasonable and necessary, what documentation will
support the need for the service, and limit coverage to specific medical
diagnosis.
Organ
and disease related panels will only be billed and paid by Medicare when all
components are medically necessary.
Tests
ordered as part of a non-AMA panel will be coded and billed separately.
Reflex
Tests
NPL generates
orders for reflex tests that are consistent with regional and national
standards of practice in an attempt to provide appropriate or useful
information to the clinician. The option
of ordering any one of these tests without the reflex is available.
CPT codes
published by NPL in the electronic or hard copy versions are provided for
informational purposes only. The codes reflect our interpretation of CPT coding
requirements based on AMA guidelines published annually. NPL assumes no responsibility for billing
errors due to reliance on CPT codes published by NPL.