CMS Pub. 100-02, ch. 15, § 80.1.2

B3-2070.1.F

An important role of the A/B MAC (B) is as a communicant of necessary information to independent

clinical laboratories. Experience has shown that the failure to inform laboratories of Medicare regulations

and claims processing procedures may have an adverse effect on prosecution of laboratories suspected of

fraudulent activities with respect to tests performed by, or billed on behalf of, independent laboratories.

United States Attorneys often have to prosecute under a handicap or may simply refuse to prosecute cases

where there is no evidence that a laboratory has been specifically informed of Medicare regulations and

claims processing procedures.

A/B MACs (B) must follow the Provider Education and Training (PET) guidelines to assure that

laboratories are aware of Medicare regulations and the A/B MAC (B’s) policy when any changes are made

in coverage policy or claims processing procedures. The PET guidelines require A/B MACs (B) to use

various methods of communication (such as print, Internet, face-to-face instruction). Newsletters/bulletins

that contain program and billing information must be produced at least quarterly and posted on the A/B

MAC (B) Web site where duplicate copies may be obtained.

Some items which should be communicated to laboratories and responsibilities that laboratories are required

to perform are:

• The requirements to have the same fee schedule for Medicare and private patients;

• To specify whether the tests are manual or automated;

• To document fully the medical necessity for pickup of specimens from a skilled nursing facility or a

beneficiary’s home, and

• In cases when a laboratory service is referred from one independent laboratory to another

independent laboratory, to identify the laboratory actually performing the test.

Additionally, when A/B MAC (B) professional relations representatives make personal contacts with

particular laboratories, the representative should prepare and retain reports of contact indicating dates,

persons present, and issues discussed. Finally, A/B MACs (B) should inform independent laboratories that

the Medicare National Coverage Determinations Manual as well as other guidelines contained in the manual

for determining medical necessity are on the Web site. A/B MACs (B) should also publish local guidelines

on its Web site; the A/B MAC (B) should not duplicate national instructions here. Timely paper or

electronic communications concerning the Internet publications to independent laboratories new to the A/B

MAC (B)’s service area are essential.