As a reminder, AmeriHealth requires participating providers to direct members and/or their lab specimens to a participating outpatient laboratory, with the following exceptions:

• in an emergency;
• as otherwise described in the applicable Benefit Program Requirements;
• as otherwise required by law.

Please note the following information specific to benefit plan type:

• HMO/POS members.* All routine laboratory services for HMO/POS members must be referred to the primary care physician?s (PCP) capitated laboratory site.
• PPO members. PPO members should use a participating laboratory, such as Laboratory Corporation of America^®, Quest Diagnostics^®, or Bio Reference Laboratory (AmeriHealth New Jersey members only) to maximize their benefits and save on out-of-pocket costs. PPO members may use a nonparticipating laboratory, but they will pay the out-of-network level of cost-sharing (i.e., copayment, coinsurance, or deductible) and will be subject to provider balance billing.
• EPO members (AmeriHealth New Jersey only). All routine laboratory services for EPO members must be referred to a participating laboratory. EPO members do not have out-of-network benefits.

In the unusual circumstance that a specific laboratory service is not available through a participating or capitated laboratory, providers must call Customer Service to obtain preapproval.

Contractual obligation to use participating providers

In accordance with your AmeriHealth Provider Agreement, except in an emergency, a participating provider should refer members only to participating providers for covered services. This includes, but is not limited to, ancillary services such as laboratory and radiology, unless the provider has obtained preapproval from AmeriHealth for the use of a nonparticipating laboratory.

When applicable under the terms of your AmeriHealth Provider Agreement, if a provider continues to direct members and/or their lab specimens to a nonparticipating laboratory and does not obtain preapproval from AmeriHealth, the ordering provider is required to hold the member harmless.

The ordering provider will be responsible for any and all costs to the member and shall reimburse the member for such costs or be subject to claims offset by AmeriHealth for such costs. In addition, further non-compliance may result in immediate termination of your AmeriHealth Provider Agreement.

Exception to the use of nonparticipating providers permitted under the terms of your agreement

If a provider (1) refers a member to a nonparticipating laboratory for non-emergent services without obtaining preapproval from AmeriHealth to do so; (2) sends a member?s lab specimen to a nonparticipating laboratory without preapproval; or (3) provides or orders noncovered services for a member, the provider must inform the member in advance, in writing, of the following:

• a list of the services to be provided;
• that AmeriHealth will not pay for or be liable for the listed services;
• that the member will be financially responsible for such services.

Visit our website to access the Member Consent for Financial Responsibility Form.

Providers should also be aware of the coverage status of the tests they order and should notify the member in advance if a service is considered experimental/ investigational or is otherwise non-covered by AmeriHealth. The member is financially responsible for the entire cost of any service that is non-covered (e.g., experimental/investigational).

If you have any questions related to the referral process for laboratory services, please contact your Provider Partnership Associate or Network Coordinator.

*AmeriHealth New Jersey members may choose to receive routine laboratory services authorized by their PCP from a participating outpatient laboratory provider other than their PCP?s capitated laboratory provider. However, please note that this requires members to have a referral issued by their PCP. Refer to the Provider Manual for Participating Professional Providers for more information.