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Horizon BCBS NJCommercial · Administrative · Medical PolicyHigh impact

Clinical Laboratory Out-of-Network Referral Chargeback for Managed Care Plans

Act
immediately
Effective date
Not stated in the notice
Identified
Oct 3, 2026

Summary

Horizon Blue will now seek to recover out-of-network laboratory and pathology payments from referring providers for Managed Care plan members. Providers must route all lab/pathology samples to preferred network laboratories unless the specific test is unavailable in-network. This chargeback policy creates direct financial liability for providers who refer to out-of-network labs without medical justification.

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What to do

immediately · 6 steps
01Billing and clinical staff must implement the following.
02Update all referral workflows and EMR templates to default all laboratory and pathology orders to Horizon's preferred laboratory network.
03Create a required checklist for providers documenting medical necessity whenever an out-of-network laboratory is used (to include specific test name, reason preferred lab cannot provide test, and clinical justification).
04Implement a pre-billing review process where claims/referrals show out-of-network lab providers are flagged for audit before submission to prevent chargeback liability.
05Distribute the Horizon preferred laboratory network list to all clinical staff and providers, with clear communication that out-of-network lab referrals without documented justification will result in provider chargebacks.
06Designate a compliance monitor to track any chargeback notices from Horizon and investigate patterns.
If missed: Failure to comply will result in direct financial recovery from the practice for out-of-network lab charges.

Original notice

Clinical Laboratory Out-of-Network Referral Chargeback for Managed Care Plans
horizonblue.com · Always check the source before changing claims.
View original ↗

Related changes

See all Horizon BCBS NJ changes →
Use Preferred LaboratoriesHighNo effective date · Provider NewsRefer Members to our Preferred LabsHighNo effective date · Provider NewsBrowse every Horizon BCBS NJ change in the policy list

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