Revised 12/16/14 Insurance Overview Provider Blue Cross Blue Shield (BCBS) Contracted Plans BCBS of Illinois BCBS of Kansas City PPO BCBS of Minnesota BCBS of Vermont Blue Cross of Idaho PPO Federal Employee Program Blue Shield of California* *Blue Shield Covered Highmark Blue Shield of Pennsylvania California and plans that begin with ID# “XEK” are Non-Contracted Plans, see guidelines below. Contracted Insurance Providers Restrictions Carefirst BCBS – includes Maryland, Washington DC, and parts of Northern Virginia BCBS of Illinois: Comprehensive Stool Analysis not covered* Capital Blue Cross, Highmark, and Blue Shield of California: IgG Food Allergy Test w/ Candida not covered* Keystone Health Plan West - Pennsylvania (HMO) Highmark West Virginia Capital Blue Cross of Pennsylvania *These tests must be paid in full at the time of Service Tricare Tricare Prime Tricare Standard Tricare for Life Medicare Medicare Medicare Advantage PPO Tests not covered: Microbial Organic Acids Test, Porphyrins Profile, Kryptopyrrole Test, Comprehensive Fatty Acids Test. Hormones Panels cannot be billed for Tricare South Medicare Advantage HMO For non-eligible tests, refer to the Advance Beneficiary Notice (ABN) included in the Test Requisition Form Medicare/Medicare Advantage does not pay for tests for which the documentation, including the patient record, does not support that the tests were reasonable or necessary, and does not cover routine screening tests. It is the responsibility of the ordering physician to document and maintain the medical necessity of each test in the patient’s medical record. Requirements: Comprehensive Stool Analysis requires payment of $94.44 Signed ABN required (see Test Requisition Form) Provider Non-Contracted Plans Non-contracted Blue Cross Blue Shield (BCBS) Anthem Blue Cross of California Blue Cross of Massachusetts HMO Cigna Harvard Pilgrim Tufts United Healthcare Eligibility Restrictions All Non-Contracted plans will require a 20% down payment (see price list) Any restricted plans or tests must pay in full at the time of service Contracted Insurance Providers and NonCovered Plans IgG Food Allergy Test not covered for: Anthem BCBS of California BCBS of North Carolina The Great Plains Laboratory files the insurance claim on behalf of the patient. Some insurance companies provide payment and Explanation of Benefits (EOB) to the patients directly. If the patient is paid directly, the endorsed check and EOB must be forwarded to The Great Plains Laboratory (endorse back of check: ‘‘Pay to the order of The Great Plains Laboratory’’ and sign). Non-Covered Tests Amino Acids Plasma or Urine Test Non-Covered Plans We are not in-network with any of these plans and will not bill to these insurance carriers. Full cash price payment required and must be submitted with specimens. A receipt will be sent to the patient. Wellmark BCBS of Iowa Humana Aetna Wellmark BCBS of South Dakota All non-eligible plans (see above) Medicaid Silver Direct Access (a plan under BCBS Florida Anthem Blue Cross of California) GEHA UMR HMO plans (except those listed United Healthcare of the River Valley above) Kryptopyrrole Test DNA Methylation Pathway Profile For any questions regarding insurance coverage, please call 913-341-8949 or 913-754-0459 Always call your insurance provider to confirm benefits as insurance coverage is subject to change. Patients are responsible for any deductibles, copayments, cost shares, coinsurance, or balance. If for any reason your insurance company deems your lab work as a noncovered or medically unnecessary service, you will be responsible for the full amount of the charge. We are currently applying for in-network coverage with several individual BCBS state programs. Please check our website for updated information at www.GPL4U.com/Insurance_Overview. Also available at this location is our insurance coverage verification guide to assist in determining coverage. NOTE: Insurance is filed in the state where the referring physician’s NPI is registered, or where the referring physician's NPI is currently located.