101 CMR, § 320.04

Current through Register 1538, January 3, 2025

Section 320.04 - General Rate Provisions and Maximum Fees

(1)Rate Determination. Payment rates are the lowest of

(a) the eligible provider's usual and customary charge to patients other than publicly aided individuals or industrial accident patients;

(b) the applicable listing from the schedule of allowable fees listed in 101 CMR 320.05; or

(c) the amount that is allowable under 42 U.S.C. § 1396b(i)(7).

(2)Individual Consideration (I.C.). Unlisted procedures and laboratory tests designated I.C. are individually considered items. The eligible provider's bill for such a test must be accompanied by a brief report of the procedure or test performed and the eligible provider's usual and customary charge for that procedure or test. Determination of appropriate payments for procedures and tests designated I.C. are in accordance with the following standards and criteria:

(a) time required to perform the procedure;

(b) degree of skill required in the procedure performed;

(c) severity or complexity of the patient's disease, disorder, or disability;

(d) policies, procedures, and practices of other third-party purchasers of care;

(e) prevailing medical-laboratory ethics and accepted custom of the medical-laboratory community; and

(f) such other standards and criteria as may be adopted by EOHHS. In no event may an eligible provider bill or be paid in excess of the usual and customary charge for the service.

(3)Administrative and Supervisory Duties. The rates of payment under 101 CMR 320.00 are full compensation for clinical laboratory services rendered to publicly aided individuals, as well as any related administrative or supervisory duties in connection with clinical laboratory services, without regard to where the service is rendered.

(4)Profile (or Panel) Tests. In no event may an eligible provider bill or be paid separately for each of the tests included within a profile test when a profile test has either been performed by the provider or requested by an authorized person.

(5)Limitations on Payment for Panel Tests.

(a) Any combination of the following tests when performed on a single patient on a single date of service is regarded as a single panel test:

80047	Basic Metabolic Panel -calcium, ionized (Consists of 82330, 82374, 82435, 82565, 82947, 84132, 84295, 84520): eight individual tests
80048	Basic Metabolic Panel -calcium, total (Consists of 82310, 82374, 82435, 82565, 82947, 84132, 84295, 84520): eight individual tests
80051	Electrolyte Panel (Consists of 82374, 82435, 84132, 84295): four individual tests
80053	Comprehensive Metabolic Panel (Consists of 82040, 82247, 82310, 82374, 82435, 82565, 82947, 84075, 84132, 84155, 84295, 84460, 84450, 84520): 14 individual tests
80061	Lipid Panel (Consists of 82465, 83718, 84478): three individual tests
80069	Renal Function Panel (Consists of 82040, 82310, 82374, 82435, 82565, 82947, 84100, 84132, 84295, 84520): ten individual tests
80076	Hepatic Function Panel (Consists of 82040, 82247, 82248, 84075, 84155, 84460, 84450): seven individual tests
82040	Albumin; serum
82247	Bilirubin; total
82248	Bilirubin; direct
82310	Calcium; total
82374	Carbon dioxide (bicarbonate)
82435	Chloride; blood
82465	Cholesterol, serum or whole blood, total
82550	Creatine kinase (CK), (CPK); total
82565	Creatinine; blood
82947	Glucose; quantitative
82977	Glutamyltransferase, gamma (GGT)
83615	Lactate dehydrogenase (LD), (LDH)
84075	Phosphatase, alkaline
84100	Phosphorus, inorganic (phosphate)
84132	Potassium; serum, plasma or whole blood
84155	Protein; total, except refractometry
84295	Sodium; serum, plasma or whole blood
84450	Transferase; aspatrate amino (AST), (SGOT)
84460	Transferase; alanine amino (ALT), (SGPT)
84478	Triglycerides
84520	Urea nitrogen; quantitative
84550	Uric acid; blood

(b) Panel tests are reimbursed according to the following schedule.

Code	Rate	Description
ATP02	$5.60	Auto Test Panel Pricing Code, 1-2 Tests
ATP03	$7.14	Auto Test Panel Pricing Code, 3 Tests
ATP04	$7.54	Auto Test Panel Pricing Code, 4 Tests
ATP05	$8.39	Auto Test Panel Pricing Code, 5 Tests
ATP06	$8.41	Auto Test Panel Pricing Code, 6 Tests
ATP07	$8.78	Auto Test Panel Pricing Code, 7 Tests
ATP08	$9.09	Auto Test Panel Pricing Code, 8 Tests
ATP09	$9.34	Auto Test Panel Pricing Code, 9 Tests
ATP10	$9.34	Auto Test Panel Pricing Code, 10 Tests
ATP11	$9.49	Auto Test Panel Pricing Code, 11 Tests
ATP12	$9.69	Auto Test Panel Pricing Code, 12 Tests
ATP13	$11.34	Auto Test Panel Pricing Code, 13 Tests
ATP14	$11.34	Auto Test Panel Pricing Code, 14 Tests
ATP15	$11.34	Auto Test Panel Pricing Code, 15 Tests
ATP16	$11.34	Auto Test Panel Pricing Code, 16 Tests
ATP17	$11.42	Auto Test Panel Pricing Code, 17 Tests
ATP18	$11.42	Auto Test Panel Pricing Code, 18 Tests
ATP19	$11.89	Auto Test Panel Pricing Code, 19 Tests
ATP20	$12.28	Auto Test Panel Pricing Code, 20 Tests
ATP21	$12.66	Auto Test Panel Pricing Code, 21 Tests
ATP22	$13.04	Auto Test Panel Pricing Code, 22 Tests
ATP23	$13.04	Auto Test Panel Pricing Code, 23 or more Tests