MACs Instructed to Remind Labs to Collect and Report Private Payor Data

Following is the text of a letter that Medicare Administrative Contractors (MACs) have been instructed to forward to all clinical laboratories by April 26, 2019.

Dear Clinical Laboratories and Hospitals:

The Protecting Access to Medicare Act of 2014 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. Therefore, CMS needs private payor data to set payment rates effective January 1, 2021. Are you required to submit data?

  • 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 then you are required to report information which includes laboratory test HCPCS codes, associated private payor rates, and volume data.

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

Going forward, applicable laboratories must submit data every three years. Visit our webpage ( for resources, including how to determine whether your laboratory is an applicable laboratory, how to report data and examples of who must report. Submit questions to We appreciate your time and effort.

For more information, see CMS Manual System, Transmittal 2279, April 12, 2019: Direct Mailing Notification to the Medicare Administrative Contractors (MACs) Regarding Clinical Laboratory Fee Schedule (PDF). Click here to view/download PDF .