If a consultative examination (CE) provider bill (or a request for payment for a provider's
services) includes a charge for a laboratory test for which payment may be made, the
amount payable is determined as follows.
If the bill (or payment request) indicates the test was personally performed or supervised
by the provider who submitted the bill (or by another provider with whom that provider
shares his/her practice), the payment will be based on the provider's usual and customary
charge for the test or the rates of payment in the State’s fee schedule, whichever
is the lesser amount.
If the bill (or payment request) indicates the test was performed by an independent
laboratory, the payment will be based on the billed cost of the independent laboratory
or the State’s fee schedule, whichever is the lesser amount. The provider may be paid
a nominal payment for obtaining laboratory samples, e.g., drawing blood, if the provider
bills for the service. However, the total reimbursement may not exceed the State’s
NOTE: States are responsible for monitoring and overseeing the rates of payment it uses
to ensure compliance with DI 39545.600C.1. and DI 39545.600C.2.