Laboratory Management Policies

Medical Mutual Laboratory Management Program Policies Disclaimer

Medical Mutual has collaborated with Avalon Healthcare Solutions (Avalon) on a Laboratory Management Program. The Laboratory Management Program includes certain Laboratory Services Policies (the “Laboratory Policies”) that offer guidance for payment determinations for a laboratory service or guidance for the way a laboratory service should be billed to Medical Mutual. The provider is responsible for submission of accurate claims.

The Laboratory Policies have been developed to assist in administering proper payment under benefit plans. Benefit plans vary in coverage and some plans may not provide coverage for some services discussed in these Laboratory Policies. Benefit determinations, coverage decisions, and payment determinations are subject to all terms and conditions of the applicable benefit plan, including definitions, specifically stated benefits, exclusions and benefit limitations, applicable state or federal laws, and other Laboratory Policies, Medical Mutual Corporate Reimbursement Policies, and Medical Mutual Corporate Medical Policies. Laboratory Policies are not intended to address every issue related to reimbursement of health care services, and Medical Mutual may use reasonable discretion in interpreting and applying Laboratory Policies to particular cases.

Laboratory Policies are considered guidelines and are not intended to infer or eliminate benefits or coverage for a specific member. Payment determinations are based on the specific facts regarding the service provided and how that service is billed.

Laboratory Policies do not constitute medical advice or medical care. The healthcare provider treating the member is solely responsible for the medical advice and treatment rendered to the member. Only the treating provider can deliver medical care and be responsible for the quality or appropriateness of the medical care and the skill with which it is provided.

Medical Mutual coverage decisions are benefit decisions only. Medical Mutual is not responsible for, does not provide and does not represent itself as a provider of medical care. If a service or supply is not eligible for benefits as determined by Medical Mutual, a member and the treating provider may proceed with that service or supply; however, benefits will not be available under the member’s plan.

Laboratory Policies are regularly reviewed, updated, withdrawn or added and therefore, subject to change. Payment determinations are made in the context of Laboratory Policies and other Medical Mutual policies, including Corporate Reimbursement Policies and Corporate Medical Policies, existing at the time the determination is made and are not subject to later revision as a result of a change in Laboratory Policy.