Lab Competitive Bidding

CMS released CR 5359 which applies to the implementation of the first Competitive Bidding Area (CBA1).

During the first quarter of 2007 CMS will provide Medicare contractors with:

• A national zip code pricing file which will identify the zip codes included in the first CBA
• A list of laboratories eligible to participate in the first CBA, including winning and passive laboratories
• A list of laboratories that are not selected to participate in the CBA1

Laboratory services covered in the demonstration in CBA1 with dates of service between April 01, 2007 and March 31, 2010, will be paid according to the competitive bidding demonstration fee schedule amounts for laboratory services on that schedule. If a service is not included in the demonstration schedule, it will be paid based on the clinical laboratory fee schedule.

Medicare will reject any claim within the date range listed above which includes Modifier 90 for demonstration covered services provided to beneficiaries residing in the CBA, regardless of the referring laboratoryÕs participation status.

Claims for non-winning laboratories with dates of service between April 1, 2007 and March 31, 2010 will be denied. Non-winning laboratories will not be allowed to transfer payment responsibility to Medicare patients with an ABN. Line items for demonstration services and non-demonstration services may be submitted on one claim.

Laboratories providing clinical laboratory services to only Medicare beneficiaries with End Stage Renal Disease (ESRD) residing in the CBA will not be required to bid in the demonstration. These laboratories will be considered ÒPassive-ESRD laboratoriesÓ. Passive ESRD labs will be paid based on the competitive bidding demonstration fee schedule for demonstration tests provided to ESRD patients residing in a CBA. ESRD labs who expand their business to provide clinical laboratory services for non-ESRD beneficiaries residing in the CBA will be terminated from the competitive bidding demonstration.

The Change Request can be viewed here. For instructions on phase one of the laboratory competitive bidding project, view the following web site.