Clinical Diagnostic Laboratories: Resources about the Private Payor Rate-Based CLFS

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 by reading:

  • Summary: Overview of key terms and concepts and how to determine whether your laboratory is an applicable laboratory
  • MLN Matters Article: Detailed information and examples to help you determine if you need to report
  • Frequently Asked Questions: Responses to questions regarding the changes effective January 1

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