Lab studies that are performed in a physician's office and billed by that physician. In some benefit designs, particularly co-payment-oriented designs, the office-visit co-pay might cover any labs or x-rays incurred at the time of the office visit:
If this is the case, select No Charge in the benefit design drop-down list for this category.
The following five benefit service categories are all found in the same section of the SBC, “If you have a test”:
- Lab Outpatient Facility
- Lab Outpatient Professional Office
- X-Rays Primary
- X-Rays Specialist
- X-Rays All Other
Sometimes all five categories have the same benefit design, in which case you should enter the same information for all of them. Sometimes, however, there is differentiation based on labs vs. x-rays, and / or place-of-service (PCP vs. Specialist vs. free-standing vs. facility). When there is differentiation, it will be described in the detail of the “If you have a test” section of the SBC (see previous image).
In many cases, there is no differentiation between facility-billed and professional-billed services in a benefit design. If this is the case, enter the singular lab benefit cost-share in this category and in the Lab Outpatient Facility category: