January 3, 2017
FAQs
Frequently Asked Questions (FAQs)
Avalon to Replace BCBSNC’s Existing Lab Network, Effective March 1,
2017
What is Avalon Healthcare Solutions (Avalon)?
Avalon Healthcare Solutions (“Avalon”) is a Laboratory Benefits Manager (LBM) that has contracted with
Blue Cross and Blue Shield of North Carolina (“BCBSNC”) to improve quality and costs related to clinical
laboratory testing. Avalon is an independent company, which will provide access to a laboratory network
designed to meet the access and clinical requirements for BCBSNC’s network of providers and the
patients they serve. Avalon and its network of laboratories understand laboratory medicine and the ways
to help ensure our members receive high-quality, cost-effective laboratory services.
What is changing?
Effective March 1, 2017, BCBSNC’s existing network of independent laboratories will be replaced with a
network managed by Avalon. Only laboratories contracted with Avalon will be eligible to provide innetwork laboratory services and receive payments under our members’ in-network benefits. By making
this switch, we can better offer our members’ access to high quality laboratory services at the most
affordable cost.
Why is BCBSNC switching its lab network to Avalon?
The cost of health care is rising for everyone and we have an obligation to ensure that our members
receive the highest quality of care at the most affordable cost. Laboratory medicine is continuing to
become increasingly complex. As technology improves, the cost and utilization of these services
increase. By making this transition, we can better offer our members’ access to high quality laboratory
services at the lowest out-of-pocket cost.
What BCBSNC products will use Avalon’s lab network?
BCBSNC’s transition of the laboratory network to Avalon will apply for all BCBSNC’s under-65
underwritten and administrative services only products, including but not limited to North Carolina State
Health Plan, the Federal Employees Program, and under age-65 members eligible through the BlueCard®
program. This change does not impact any laboratory’s existing participation in BCBSNC’s Medicare
Advantage products.
What laboratories are required to join Avalon?
All independent reference laboratories that file claims reporting POS 81, and which provide laboratory
services for BCBSNC’s under age-65 members who are enrolled in either insured or administered plans,
must be contracted with Avalon for eligibility to provide in-network services for those members, starting on
and for dates after March 1, 2017.
How will BCBSNC communicate which independent reference laboratories will be in Avalon ’s
network?
Early in 2017, BCBSNC will publish on our website bcbsnc.com a list of the independent reference
laboratories included in the Avalon network. The list will be maintained separately from our online
provider directory, “Find a Doctor.” We will also make updates to the list as we move toward March 1,
2017. The laboratories included on the website listing will be in the Avalon network and eligible to receive
referrals from in-network providers to perform laboratory services for their patients.
Independent reference laboratories included in BCBSNC’s “Find a Doctor” online directory are listed
accurately, as in-network laboratories for providing services until February 28, 2017.
On and after March 1, 2017, members and providers will be able to verify the participation status of
independent reference laboratories by using BCBSNC’s “Find a Doctor” online directory, located at
bcbsnc.com.
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What this means for referring providers and members is:
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When making referrals to Independent reference laboratories for services to be performed prior to
March 1, 2017, BCBSNC’s “Find a Doctor” online directory should be utilized to locate a
participating laboratory.
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When making referrals to Independent reference laboratories for services to be performed on and
after March 1, 2017, but ordered before March 1, 2017, BCBSNC’s published list on our website
of the independent reference laboratories included in the Avalon network should be utilized.
BCBSNC’s “Find a Doctor” online directory should not be utilized.
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When making referrals to Independent reference laboratories for services to be performed on and
after March 1, 2017, BCBSNC’s “Find a Doctor” online directory should be utilized to locate a
participating laboratory if the services are also being order on and after March 1, 2017.
Can providers refer laboratory tests and services to independent reference laboratories not in
Avalon’s network?
No, starting March 1, 2017, only laboratories contracted with Avalon will be eligible to provide in-network
laboratory services for members under age-65 and enrolled in underwritten and administrative services
only products. Just as with the rules for referring laboratory services to independent laboratories within
our existing network, participating providers and facilities will be requested to adhere to their contractual
obligation to send all referred laboratory services to in-network, independent reference laboratories.
As of March 1, 2017, Avalon’s network of independent reference laboratories will be considered the “innetwork” network for BCBSNC’s under-65 underwritten and administrative services only products,
including but not limited to North Carolina State Health Plan, the Federal Employees Program, and under
age-65 members eligible through the BlueCard program.
What will happen if a provider makes a referral to a laboratory not in Avalon’s network on or after
March 1, 2017?
If the out-of-network lab performs the service that has been referred to it, the claim for the service will be
processed as out-of-network. BCBSNC and our members depend on participating providers to use the
services of in-network laboratories. The costs of laboratory services are aligned to your BCBSNC
patients’ benefit designs, which offer the lowest out-of-pocket cost for patients when in-network services
are obtained. Referrals of services to out-of-network laboratories can subject patients to much higher
out-of-pocket costs, which can include the total costs when out-of-network benefits are not available.
Referring providers are contractually required to refer in-network, and can risk termination of their innetwork participation with BCBSNC, when failing to utilize the services of in-network laboratories for their
reference lab testing and servicing needs.
What should independent reference laboratories do if not already in Avalon’s network?
In order to avoid losing in-network participation status with BCBSNC on March 1, 2017, independent
reference laboratories not already in Avalon’s network must reach agreement with Avalon well in advance
of that date for participation in the new BCBSNC network. BCBSNC is encouraging those laboratories to
contact Avalon, as soon as possible to complete the contracting process, to ensure continued access to
BCBSNC members and referrals from our in-network physicians, on and after March 1, 2017. Avalon can
be contacted to begin the contracting process by email at NetworkTeam@A valonHCS.com.
How are currently participating independent reference laboratories being notified regarding the
need to contract with Avalon ?
Laboratories are being notified by letters sent via U.S. Postal Mail. The distribution of the letters will
staggered and not all laboratories will receive their letters at the same time. The first letters are being
sent in December 2016, and additional laboratories will be notified in early 2017. All independent
reference laboratories that bill using POS 81, and participate in BCBSNC’s network for under age-65,
underwritten and administrative services only products will be receiving letters.
Is additional information about Avalon available ?
Yes, additional information about Avalon is available on their website located at www.avalonhcs.com.
About Avalon’s processes for claims administration
How are claims for services filed by independent reference laboratories handled?
Claims from laboratories participating in the Avalon network , when billed for services provided to
BCBSNC’s members, are submitted to Avalon. Avalon sends BCBSNC information about the claims,
including information about the specific servicing laboratories. BCBSNC then processes the claims and
sends details about the processed claims back to Avalon, along with payment for the claims. Following
final processing of claims by BCBSNC, Avalon settles payment with the participating laboratory according
to their contract with Avalon.
Can independent reference laboratories contracted with Avalon file claims directly to BCBSNC?
Not if the claims report services performed on or after March 1, 2017, and are provided for BCBSNC’s
members enrolled in under-65 underwritten and administrative services only products, including but not
limited to North Carolina State Health Plan, the Federal Employees Program, and under age-65 members
eligible through the BlueCard program.
BCBSNC subcontracts certain provider network services for independent laboratory services to Avalon.
Laboratories participating in the Avalon network must submit claims to Avalon for services provided to
BCBSNC members (including claims for BlueCard eligible members). Avalon forwards submitted claims
to BCBSNC for final processing before payment is made to the laboratory by Avalon.
What claims continue to be filed directly to BCBSNC after March 1, 2017?
Laboratories contracted with Avalon should send claims directly to BCBSNC if the laboratory services are
performed on or before February 28, 2017.
Claims for BCBSNC’s Medicare Advantage and Medicare Supplemental plans will continue to be filed
directly to BCBSNC.
Claims from non-Avalon participating laboratories for services provided for members enrolled in under
age-65, underwritten and administrative services products, will continue to be filed directly to BCBSNC for
out-of-network processing.
What will happen if a laboratory claim that should be sent to Avalon goes to BCBSNC?
The claim will be denied by BCBSNC with instructions to refile. Avalon submits all claims for services
provided by laboratories participating in the Avalon network. To prevent routing errors, BCBSNC has
established EDI edits to alert providers to submit these claims to Avalon.
Will referring providers’ claims be impacted?
No, providers who refer lab services for their patients should continue to bill BCBSNC for the services
they perform. However, those referring providers’ contracts may be impacted if they do not comply with
their contractual obligation to refer in-network.
How can independent reference laboratories find additional information about joining Avalon and
getting their businesses setup to file claims and receive payments from Avalon?
Laboratory providers can contact Avalon directly for information about contract participation, including
reimbursement for services and how to file claims for services. For assistance Avalon can be reached by
emailing to NetworkTeam@A valonHCS.com.