Subsection 144-101-II-55.04 - COVERED SERVICES55.04-1General ProvisionsA covered service is a service for which payment can be made by the Department.
Laboratory Services which are medically necessary for diagnosis and control of a medical condition, are covered services. These services must be ordered by a physician or other licensed practitioner of the healing arts authorized to order lab services within the scope of his or her license and be consistent with good medical practice.
55.04.2Bundling or Grouping of Laboratory TestsPanels are tests that are frequently done as a group (profile) on automated equipment. If a group of tests overlaps two or more panels, the panel that incorporates the greater number of tests to fulfill the code definition is reimbursable. The remaining tests are individually reimbursable. Additionally, the provider shall not "unbundle" and bill separately for tests included as part of a group (profile or panel) that pay at a lower rate. Use the Physicians' Current Procedural Terminology (CPT) Manual Codes for the proper Automated, Multichannel Tests, and for the proper Organ or Disease Oriented Panels.
As noted in Section 55.07(B) Medicaid will pay no more than the lowest amount payable by Medicare. Therefore, in those cases where the Medicaid allowance for a procedure exceeds the Medicare allowance, the program will pay the lowest Medicare-allowed rate.
55.04-3Drug TestingA. decision making for all drug testing including urine drug screening and confirmation testing must be supported by documentation in the medical record maintained by the individual's physician or other licensed practitioner as provided by Section 55.04-1. B. Frequency and choice of assay used should be based on medical necessity and a complete clinical assessment of the individual member's risk potential for abuse and diversion.C. The Department will not make separate payment for the testing of adulterants or specimen validity. There are a number of multi-panel, CLIA waived urine drug test kits available which test for pH, specific gravity, and oxidants to determine if the specimen has been adulterated.D. Confirmation testing is covered only to: 1. Confirm an unexpected result; or2. Identify specific drugs or metabolites that cannot be detected on a urine drug screen. Confirmation tests should be based on the member's presentation and history and only include what is needed for safe patient management. The definitive test(s) must be supported by documentation that specifies the rationale for each definitive test ordered. Drug confirmation testing must be performed by a second method. A presumptive test cannot be performed to confirm a presumptive test. Confirmation testing must be requested in writing by the ordering provider.
E. Urine drug testing is limited to three (3) specimens per rolling month. Additional test(s) may be requested with a Prior Authorization, to be issued in six (6) month authorizations. Individuals meeting the following criteria are exempt from this limitation, and are not required to seek Prior Authorization for testing beyond three (3) specimens per month: 2. Members involved with an active Office for Child and Family Services (OCFS) case;3. Members in Intensive Outpatient Treatment (IOP);4. Members being established in Medication-Assisted Treatment (MAT) up to six months (including methadone, sub oxone, and other MAT treatments);5. Members receiving services in an Emergency Department; and6. Members in Residential Treatment for substance abuse (Chapter 97 Appendix B facilities)F. Substance abuse treatment is to be measured by random testing rather than scheduled testing.G. Routine urine drug screening is a presumptive procedure that should focus on detecting the specific drug(s) of concern based on the member's medical history and/or the prevalence of drugs, geographically.H. Standing orders written to the laboratory for presumptive testing must be signed and dated by the ordering provider no more than six (6) months prior to the date of specimen collection. Standing orders must contain the frequency of laboratory testing and be documented in the member's record. Standing orders for confirmation and/or quantitative testing are prohibited. I. The following are not medically necessary:
1. Tests performed by an in-house laboratory and independent laboratory for the same test on the same date of service.2. Testing for residential monitoring.3. Specimen validity testing.4. Urine drug testing ordered by third parties, such as schools, employers, or requested by a provider for the sole purpose of meeting the requirements of a third party. C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-55, subsec. 144-101-II-55.04