CommercialCoverageHigh impact
24-433 New Claims Edit for Non-Covered Lab Services
Health Net·CA·Reimbursement
Effective date
Jul 12, 2024
We identified it
Jun 20, 2026
Summary
Health Net is implementing new claims edits effective July 12, 2024, that will automatically deny diagnostic lab services when billed with only non-covered diagnosis codes per Medicare NCD guidelines. This policy applies to both professional and outpatient facility claims for Commercial lines of business following CMS requirements.
Action Required
Immediately: Verify all diagnostic lab service claims use covered diagnosis codes per Medicare NCD guidelines before submission. Review the complete NCD Lab Code List on the CMS website to ensure compliance. For patients with non-covered conditions, obtain Advance Beneficiary Notice of Noncoverage (ABN) before performing tests. Update billing procedures to cross-reference diagnosis codes with NCD requirements for all 62 affected lab CPT codes. Claims with only non-covered diagnosis codes will be automatically denied.