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CMS Lab Ordering Guidelines Reminder

Dear Medicare Provider,

Thank you for being a valued partner, providing quality patient care to Wellcare Medicare members.

We understand how critical receiving timely claims payments and services are for providers to ensure the best level of care possible to our members. It has, however, been brought to our attention by our National Lab Vendors that there has been an increase in labs submitted that are not following Center for Medicare & Medicaid Services (CMS) guidelines related to services and diagnosis being populated on the order. As a result, when the Lab performs the service and submits the claim for reimbursement, these claims are being denied. This is due to the order not meeting billing criteria for reimbursement.

It is vitally important when ordering labs that you follow all CMS Billing Guidelines (PDF). These outline regulatory guidance as well as required information and details that must be included when ordering patient labs. This aids in timely processing and payment. Departure from these guidelines and omission of required information result in lab claims getting delayed, rejected, or denied.

The CMS Lab Billing Guidelines covers the following topics:

  • Insufficient Documentation
  • Documentation Requirements
  • Medicare Signature Requirements
  • Ordering or Referring Services

Thank you for your continued participation in our network and products. And, thank you for your partnership to resolve this urgent issue.

If you have any questions, please do not hesitate to contact your Provider Representative.


Wellcare Health Plans

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Last Updated On: 11/17/2022