PAMA Regulations

IMPORTANT UPDATE

CLFS Data Reporting Delayed

  • For Clinical Diagnostic Laboratory Tests (CDLTs) that are not Advanced Diagnostic Laboratory Tests (ADLTs), the data reporting is delayed by one year.  CDLT data that was supposed to be reported between January 1, 2020 and March 31, 2020, must now be reported between January 1, 2021, and March 31, 2021.  Labs must report data from the original data collection period of January 1, 2019 through June 30, 2019.  Data reporting for these tests will then resume on a three-year cycle, beginning in 2024. (Section 105(a)(1) of the  Further Consolidated Appropriations Act of 2020 (FCAA)).
  • In addition, the statutory phase-in provisions are updated.  For 2020, the rates for CDLTs that are not ADLTs or new CLDTs may not be reduced by more than 10% of the rates for 2019.  There will be a 15% reduction cap for each of 2021, 2022, and 2023.  (Section 105(a)(2) of FCAA).

CDLT Rates

Based on Reporting Period

Reduction Cap

2020

January 1, 2017 – May 30, 2017

10%

2021

January 1, 2017 – May 30, 2017

15%

2022

January 1, 2021 – March 31, 2021

15%

2023

January 1, 2021 – March 31, 2021

15%


Do I need to submit private payor rates? 
When do I submit private payor rates? 
How do I report private payor data? 
Advanced Diagnostic Laboratory Tests (ADLTs)  
How do I notify CMS of FDA Cleared or Approved CDLTs? 
Where do I find CY 2018 private payor rates and supporting information? 
Questions?

   

Do I need to submit private payor rates?

The Protecting Access to Medicare Act of 2014 (PAMA) required significant changes to how Medicare pays for clinical diagnostic laboratory tests under the Clinical Laboratory Fee Schedule (CLFS). Effective January 1, 2018, the payment amount for most tests equals the weighted median of private payor rates. Payment rates under the private payor rate-based CLFS are updated every three years. 

If you are a laboratory, including an independent laboratory, a physician office laboratory or hospital outreach laboratory that meets the definition of an applicable laboratory you are required to report information including laboratory test HCPCS codes, associated private payor rates, and volume data.

Learn more:

  

When do I submit private payor rates?

If you meet the applicable laboratory criteria, act now using this schedule:

  • January – June, 2019: Collect data
  • July – December, 2019: Analyze data
  • January – March, 2021: Report data

  

How do I report private payor data?

 

Advanced Diagnostic Laboratory Tests (ADLTs)

 

Notify CMS of FDA Cleared or Approved CDLTs

 

Where do I find CY 2018 private payor rates and supporting information?

CMS published the final payment rates and supporting documentation for the new private payor rate-based CLFS payment system.  These rates were implemented on January 1, 2018.  The files include: 

Final Payment Rates and Crosswalking/Gapfilling Determinations 

  1. CY 2018 Final Crosswalking/Gapfilling Determinations (PDF) (for new and existing laboratory test codes for which CMS received no applicable information to calculate a private payor rate-based CLFS payment amount).
  2. CY 2018 Final Private Payor Rate-Based CLFS Payment Rates (ZIP)
  3. HCPCS Codes with Revised Final CY 2018 Private Payor Rate-Based CLFS Payment Rates and Clarifications Regarding the Weighted Median Calculations (PDF)

 

CLFS Preliminary Payment Rates and Supporting Documentation:

 

Questions?

More Questions:

  

Page Last Modified:
06/24/2020 04:06 PM