Laboratory Billing and Credentialing Services

Laboratory billing punishes volume. A badly set up panel does not cost you one claim. Nor does a diagnosis code that fails to support the test. It then costs you every claim of that type until somebody notices. At high test volumes, that is a very large number.

Our laboratory billing services cover independent clinical labs, physician office labs, toxicology and molecular labs. We also run the lab credentialing service side. A full laboratory credentialing service covers CLIA, enrollment and the payer network applications. If you are looking for a credentialing service for labs rather than billing alone, that is the same team. Lab billing services are worth very little until the lab is actually enrolled.

CLIA: the certificate decides what you can bill

Every lab testing human specimens needs a CLIA certificate. The certificate type controls which tests you may perform and bill:

The CLIA number goes on the claim. Billing a test above your certificate complexity level is a compliance problem, not just a denial. So we check your test menu against the certificate at onboarding.

Enrollment and payer lab networks

• NPI type 2 for the laboratory entity, with the correct laboratory taxonomy.
• CMS-855B enrollment through PECOS, with the CLIA certificate attached.
• Each state Medicaid program and then each managed care plan separately.
• Commercial lab networks: and this is where most labs hit a wall. Several large carriers run closed or delegated laboratory networks. An independent lab is then out of network by default, however good its menu is. Where the network is closed we go for single case agreements and out-of-network arrangements instead. And we tell you plainly when a network cannot realistically be joined.

Medical necessity, LCDs and ABNs

Lab coverage is driven by diagnosis. Medicare publishes National and Local Coverage Determinations listing which ICD-10 codes support which tests, and a claim carrying an unsupported diagnosis denies cleanly and predictably.

• We map your most-ordered tests to their covering diagnoses and flag the orders that will not pay before the specimen is run.
• Where a test is likely to be denied as not medically necessary, an ABN signed before collection is what makes the patient responsible. Without it, the balance is written off.
• Panels are a frequent problem: ordering a panel when the documentation supports two of its components invites both denial and audit.

Molecular, genetic and PLA codes

Molecular diagnostics are the highest-value and highest-risk claims a lab files:

• Tier 1 molecular CPT codes for specific well-defined analytes.
• Tier 2 and unlisted codes, which almost always require a narrative and a price justification attached.
• PLA (Proprietary Laboratory Analyzes) codes: test-specific codes for a named assay from a named lab. Using the correct PLA code rather than a generic stack of Tier 1 codes is usually the difference between payment and a unit-count denial.
• MolDX program requirements in participating MAC jurisdictions, including technical assessment and a registered identifier for the assay.
• Prior authorization for genetic testing is now standard at many commercial plans.

Toxicology and definitive drug testing

Toxicology has its own denial pattern: presumptive versus definitive code selection, unit limits on the number of drug classes billed, and payer policies that cap definitive testing per encounter. We apply the payer's own limits at charge entry instead of billing the full panel and appealing afterwards.

What we do every week

• Eligibility and benefit checks, including lab network status for that member's plan.
• Order and diagnosis validation against LCD and payer policy before billing.
• Charge entry with correct panel, PLA and modifier selection, including QW where required.
• Prior authorization for genetic and high-cost testing.
• ABN workflow for predictable non-coverage.
• Claim submission and rejection work at volume.
• Denial management and appeals with clinical documentation attached.
• Payment posting, fee schedule reconciliation and aged AR recovery.