Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 401.000 - Independent Clinical Laboratory Services
Section 401.416 - Request for Laboratory Services

Universal Citation: 130 MA Code of Regs 130.401

Current through Register 1531, September 27, 2024

(A) Request Requirements. The independent clinical laboratory may not bill for a service unless it has received a written request to perform that specific service from an authorized prescriber who is treating the member and will use the test for the purpose of diagnosis, treatment, or an otherwise medically necessary reason as defined in 130 CMR 450.204. Any independent clinical laboratory billing for a service must maintain such request in its records, and make such records available to the MassHealth agency and the Attorney General's Medicaid Fraud Division upon request. If the laboratory that billed for the service cannot produce the original request, the MassHealth agency may deny or recover payment for all services the laboratory provided based on that request.

(B) Standing Orders. An authorized prescriber may request an independent clinical laboratory to perform one or more tests on a single date, or issue a standing order for such tests. Standing order requests may not exceed 180 days in length with the exception of standing order requests for substance abuse testing, which may not exceed 30 days in length. Standing order requests are not permissible unless such repeated tests are medically necessary and required as part of the member's medical or drug treatment plan.

(C) Required Information. Requests for laboratory services must be written and include the following information:

(1) the date of the request;

(2) the name or any other means of identifying the member to be tested;

(3) the name and address of the authorized prescriber (if the authorized prescriber is a Massachusetts Department of Public Health licensed substance abuse treatment program for the sole purpose allowed pursuant to 130 CMR 401.402, the request must include the names and addresses of both the substance abuse treatment program and the physician initiating the request);

(4) the name of the specific laboratory tests to be performed;

(5) the frequency for performing each laboratory test (applicable to standing orders only);

(6) the duration and maximum number of times each laboratory test or tests are to be performed (applicable to standing orders only); and

(7) a statement by the authorized prescriber that such testing is required as part of the member's medical or drug treatment plan (applicable to standing orders only).

(D) Recordkeeping. If a laboratory refers a specimen to a testing laboratory, the referring laboratory must forward the original request to perform the service to the testing laboratory. The testing laboratory must maintain such request in its records in accordance with 130 CMR 401.416(A).

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