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Specialized
Services

We create individualized and tailored company Market Access and Reimbursement portals (password protected) providing resources such as:

1 

Test coding information across the enterprise or specific product lines:

  • Relevant test CPT® codes 

  • Code limitations (MUE’s, National Correct Coding Initiative (NCCI) edits, etc.)

  • CLFS reimbursement rate information by geography

  • LOINC code information

2

Test coverage information:

  • Medicare coverage determinations (e.g., links to Local / National Coverage Determinations (NCD / LCD) and billing articles 

  • Commercial payor medical policies (e.g., links to select medical policies) 

  • Medical policy analysis (e.g., key policy takeaways, testing requirements, restrictions, payor historical perspectives, etc.)

3

Relevant professional medical society guidelines / opinions:

  • NCCN, ASCO, IDSA, AMP, MAD-ID, ACOG, ACMG, etc.

4

Denied claims support documents:

  • Letters of Appeal templates

  • Sample Letters of Medical Necessity

5

Potential Additional Resources:

  • Coding and reimbursement pathways: 

    • AMA CPT® code submission info (CAT I, MAAA, PLA, etc.) processes, advantages and disadvantages, establishing a reimbursement rate through CMS, etc.

    • Code utilization and review (e.g., Not Otherwise Classified / NOC /
      Miscellaneous code analysis)

    • DEX™ Diagnostics Exchange Registry ‘Z’ code information

    • CMS structure and LCD / NCD processes / MolDX® Technology Assessment information

    • Medical policy and contracting

      • Gaining in-network status – contracting

      • Evidence Development / payor perspective

      • Lab Benefit Management (LBM) companies and payor relationships (e.g., ECRI, Evidence Street, eviCore, Carelon)

    • The U.S. Preventive Services Task Force (USPSTF) recommendations (if applicable)

    • The Technology Assessment (TA) Program at the Agency for Healthcare Research and Quality (AHRQ) information (if applicable)

  • Testing classification

    • LDT vs IVD vs RUO information and considerations

    • FDA information and links (e.g., Breakthrough Designation, cleared / approved CDx devices, cleared or approved nucleic acid-based tests, etc.)

Coding is a clinical decision and should be to the highest level of specificity.  Any examples are provided for informational purposes only.  Information is subject to change; contact the appropriate payor for specific current coverage and coding guidance.  Individual patient billing will vary based on multiple factors and determination of coverage, coding, or reimbursement is not implied.  Coverage, deductible, coinsurance, and copay is based upon payor/plan specifics and/or payor contracts.  CPT® codes and descriptions are copyright of the American Medical Association.  CPT® is a registered trademark of the American Medical Association (AMA).  All rights reserved.  Any analysis is not meant to be a complete representation of all potential complex scenarios, it is based on Reimbursement Hub’s understanding of the current landscape and derived from content sources deemed reliable.  Reimbursement Hub does not represent the information to be complete or accurate and should not be interpreted as such.  Final company decisions should be based on expert legal, regulatory, and financial counsel.

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