Collaboration with Avalon Healthcare Solutions

Optima Health is proud to announce our new collaboration with Avalon Healthcare Solutions (Avalon) on a new laboratory benefit management program. Avalon will be providing Routine Testing Management (RTM) services to Optima Health. RTM, an automated review of high-volume, low-cost laboratory tests, provides consistent application of laboratory policies while remaining provider and member friendly.

Here are the details:

  • Effective October 1, 2021 new and revised medical policies and guidelines will take effect for select laboratory, services, tests, and procedures. These policies and guidelines are now available for review.
  • 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.

In the coming weeks both Optima Health and Avalon will send additional email correspondence further explaining this new program as well as announcing provider education opportunities. If you have questions about any of this information, please contact your network educator at 1-877-865-9075, Option 2.

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