Laboratory Test in Hospital


Date: May 15, 2024
From: Health Plan
To: Health Plan of San Joaquin/Mountain Valley Health Plan (Health Plan) Laboratory Providers and Inpatient/Outpatient Facilities
Type: Regulatory
Subject: Laboratory Test in Hospital
Business: Medi-Cal Managed Care

Through the new Claims Editing System (CES), Health Plan has identified when billing laboratory codes, the concept of professional and technical component splits (TC/26) does not apply when billed with a place of service of inpatient (21) or outpatient hospital (22) under Centers for Medicare and Medicaid Services (CMS) and DHCS/Medi-Cal guidelines.

Exceptions:

  • Date of service must be the date the specimen is collected, and tests performed on stored specimens 14 days or more after discharge.
  • Chemotherapy Sensitivity tests are performed on live tissue 14 days or more after discharge.
  • Advanced Diagnostic Laboratory Tests and Molecular Pathology test performed after discharge.

Under these guidelines, providers will no longer be eligible for separate reimbursement from the Health Plan for the professional component when done in a hospital laboratory setting. 


If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj-mvhp.org/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website WWW.HPSJ-MVHP.ORG

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