Laboratory Benefit Management

Avalon will be providing Routine Testing Management (RTM) services to Optima Health. RTM, an automated review of high-volume, low-cost laboratory tests

  • Revised medical policies and guidelines for select laboratory, services, tests, and procedures are now available for review using this link
  • Laboratory services reported on claims will be reviewed for adherence and consistency with Optima Health laboratory policies and guidelines, as well as industry standardized rules, such as but not limited to; evaluating services for being experimental and or investigational; and meeting clinical appropriateness for patient demographics. Additionally, codes reporting multiple units billed will be reviewed for appropriateness to code specific unit allowances under Optima Health laboratory policies and guidelines.
  • Avalon's automated policy enforcement will be applied by Optima Health to claims with laboratory services provided in office, hospital outpatient and independent laboratory locations.
  • Laboratory services, tests and procedures provided in the emergency room, hospital observation, and hospital inpatient settings are excluded from this program.
  • Avalon's automated policy enforcement is designed to ensure the consistent application of Optima Health laboratory policies and guidelines to claims with laboratory services.

If you have questions about any of this information, please contact your network educator at (877) 865-9075, Option 2.

Sign in to Provider Connection to access the laboratory benefit management tool

Frequently Asked Questions