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PAMA Regulations

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, 2020: Report data

You need to report every three years using this timeframe.

  

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 (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
  3. HCPCS Codes with Revised Final CY 2018 Private Payor Rate-Based CLFS Payment Rates and Clarifications Regarding the Weighted Median Calculations

 

CLFS Preliminary Payment Rates and Supporting Documentation:

Questions?

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