Payment integrity
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Centene · payment integrity
Claims editing
Laboratory panel and component billing
How component laboratory tests billed alongside the panel that contains them are adjudicated.
Current version
v5.0
in force since 2025-10-01 · as at 2026-04-02
Versions on file
2
back to 2024-01-01
Applies to
All lines of business
All states
Cited in this batch
3
claims tested against it
Where this sits
OwnerClaims Editing Governance
Lines of businessAll lines of business
StatesAll states
External basisCMS NCCI procedure-to-procedure edits · CPT organ and disease panel definitions
Version history
v5.0
2025-10-01 → current
In force now
The NCCI procedure-to-procedure file is now consumed quarterly and applied at its published effective date, rather than being restated in this policy.
No source document in the index. A finding on this version can
cite it by name but cannot quote a passage.
- A component test bundled into a panel by an NCCI column 1 / column 2 pair is not separately payable.
- A modifier indicator of 1 allows the bundle to be broken with an appropriate modifier; an indicator of 0 does not.
- The component, not the panel, is the recoverable line.
v4.4
2024-01-01 → 2025-09-30
Superseded
Panel bundling enumerated in an appendix to this policy, refreshed annually.
No source document in the index. A finding on this version can
cite it by name but cannot quote a passage.
- A component test listed in Appendix B as part of a billed panel is not separately payable.
Claims in this batch tested against this policy
| Claim | Date of service | Version applied | Role | Paid | At risk |
|---|---|---|---|---|---|
| CLM-0000009 | 18 Mar 2026 | v5.0 | Decisive | $14.49 | $3.93 |
| CLM-0000007 | 06 Mar 2026 | v5.0 | Supporting | $7.77 | — |
| CLM-0000011 | 16 Mar 2026 | v5.0 | Supporting | $10.56 | — |
This policy is synthetic — an internal document written for this demo. The external basis it cites is real.