MedicaidAdministrativeHigh impact
Reminder: Billing Requirements for Clinical Laboratory Services
NC Medicaid - NCDHHS·NC·Claims & Billing
We identified it
Jun 25, 2026
Summary
NC Medicaid clarifies that only the performing laboratory may bill for clinical laboratory testing; ordering providers cannot bill for tests performed by external laboratories but may bill for specimen collection services. In-house labs must have appropriate CLIA certification and use the laboratory taxonomy. Individual ordering provider NPI is required on drug testing claims. This policy applies to NC Medicaid Direct and Managed Care plans.
Action Required
IMMEDIATELY: Billing team must implement the following: (1) Audit all current laboratory billing practices to identify claims where ordering providers are billing for tests performed by external/reference laboratories—these claims are non-compliant and must be stopped; (2) Update billing system edits to prevent ordering providers from billing laboratory procedure codes when the performing laboratory is external; (3) Verify that all in-house laboratory claims include CLIA certification verification in the system; (4) Confirm all in-house laboratory claims are submitted under the laboratory taxonomy (not ordering provider or clinic taxonomy); (5) Ensure all drug testing claims include the individual ordering provider NPI in the required field; (6) Train all billing and clinical staff that specimen collection (when separately reimbursable) is the only service ordering providers may bill for laboratory work performed by others; (7) Review current accounts receivable for potential recoupment exposure related to non-compliant laboratory billing. Failure to comply will result in claim denials, recoupments, and compliance issues with NC Medicaid.