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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that the Clinical Laboratory Improvements Amendments of 1988 (CLIA) mandates that virtually all laboratories, including physician office laboratories (POLs), meet applicable Federal requirements and have a CLIA certificate in order to receive reimbursement from Federal programs. CLIA also lists requirements for laboratories performing only certain tests to be eligible for a certificate of waiver or a certificate for Physician Performed Microscopy Procedures (PPMP). Since 1992, A/B MACs (B) have been instructed to deny clinical laboratory services billed by independent laboratories which did not meet the CLIA requirements. POLs were excluded from the 1992 instruction but included in 1997. 

The CLIA number must be included on each claim billed on the ASC X12 837 professional format or Form CMS-1500 claim for laboratory services by any laboratory performing tests covered by CLIA. 

You can find this rule in the Medicare Claims Processing Manual Chapter 16, Section 70.1. 

The rules say effective January 19, 1993, a laboratory that holds a certificate for provider-performed microscopy procedures may perform only those tests specified as provider-performed microscopy procedures and waived tests and no others. You can find this rule in the Medicare Claims Processing Manual Chapter 16, Section 70.6. 

The rules say the Food and Drug Administration approves CLIA waived tests on a flow basis. The CMS identifies CLIA waived tests by providing an updated list of waived tests to the A/B MACs (A) and (B) on a quarterly basis via a Recurring Update Notification. To be recognized as a waived test, some CLIA waived tests have unique HCPCS procedure codes, and some must have a QW modifier included with the HCPCS code. You can find this rule in the Medicare Claims Processing Manual Chapter 16, Section 70.8. 

The rules say a facility that submits a claim for any test mentioned in the HCPCS codes that are subject to CLIA edits list must have either a valid, current CLIA certificate of registration (certificate type 9), a CLIA certificate of compliance (certificate type 1), or a CLIA certificate of accreditation (certificate type 3). 

For a list of the specific HCPCS codes subject to CLIA edits refer to the following Internet site: http://www.cms.hhs.gov/CLIA/downloads/Subject.to.CLIA.pdf. You can find this rule in the Medicare Claims Processing Manual Chapter 16, Section 70.9. 

The rules say a Certificate for Provider-performed Microscopy (PPM) procedures is issued to a laboratory in which a physician, midlevel practitioner, or dentist performs only the microscopy tests listed at 42 CFR 493.19(c) or performs only the listed microscopy tests in any combination with waived tests during a patient's visit. A certificate for PPM procedures is valid for a 2-year period. Upon certificate expiration, and after payment of appropriate fees, the laboratory's certificate will be renewed for another 2-year period. You can find this rule in the State Operations Manual Chapter 6, Section 6006.3.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.