Updated: April 21, 2022
Effective May 1, 2022, Blue Cross and Blue Shield of Montana (BCBSMT) will implement its new program with Avalon Healthcare Solutions for claims for certain outpatient laboratory services provided to many of our commercial members.
This new program will be rolled out incrementally:
- Fully-Insured members effective 5/1/2022
- Self-funded member groups may opt in upon renewal in 2023
- Frequency edits with applicable claims history will be rolled out tentatively effective 6/1/2022
This program does not apply to government programs.
The new program will:
- Help ensure our members have access to the right care at the right time and in the right setting
- Better prepare you to submit claims that support and reflect high quality, affordable care delivery to our members
See below for key points to help you prepare.
Policy Updates
It is your responsibility to keep up to date with new and revised Laboratory Management Program Clinical Payment and Coding Policies effective May 1, 2022 and after, related to certain laboratory services, tests and procedures.
Affected Claims
Our new program may include the following outpatient laboratory claims:
Performed in an outpatient setting (typically office, hospital outpatient or independent laboratory)
Laboratory services provided in an emergency room, hospital observation or hospital inpatient settings are excluded from this program. Member coverage terms still apply.
Provider Resources
Self-service Trial Claim Advice Tool via Availity® available 24/7
You can get free access to Avalon’s Trial Claim Advice Tool by registering at Availity.com, which will allow you to input laboratory procedure and diagnosis codes to see, before submitting a claim, the potential outcome of your claim.
- The Trial Claim Advice Tool does not guarantee approval, coverage, or reimbursement for health care services
- Potential claim outcomes provided by Avalon’s Trial Claim Advice Tool consider information entered into the tool for the date of service entered
- Historical claims auditing related to frequency edits (tentatively scheduled for availability on 6/1/2022)
- Applicable referenced Policy Names and Tags in the tool can be located on our secure provider portal at Clinical Payment and Coding Policies
- NOTE: The Trial Claim Advice Tool Application Pages are the only pages of information applicable to BCBSMT providers in the Avalon portal (the Documents and Media Pages content is not applicable)
Questions? Contact your BCBSMT Provider Network Representative.
Avalon Health Solutions (Avalon) is an independent company that provide claims management services for members with coverage through BCBSMT. BCBSMT makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Avalon.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSMT. BCBSMT makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity.