- 4009 Hackney Springs Ln, Sachse, TX 75048
| STATES / TERRITORIES | PHONE · PORTAL | CLAIM VOLUME | BENEFICIARIES |
|---|---|---|---|
| 1-855-252-8782 · Novitasphere JL | ~200 million claims/year | ~3.4 million Medicare FFS |
Novitas Solutions does not participate in the MolDX program for JH. Labs billing molecular diagnostic tests, CPT codes in the 81XXX range, or most PLA codes do not need a Palmetto GBA DEX Z-Code to submit those claims; they bill under standard CPT/ICD-10 coding per the applicable LCD instead.
L35025 — MolDX: Molecular Diagnostic Tests (MDT). Governs Z-Code requirements for every molecular or genetic test billed in J5. Submit a Test Coverage Review at dexzcodes.com before billing.
| LCD | Coverage Area | Key Requirement |
|---|---|---|
| L35062 | Glycated Hemoglobin / Glycated Protein (HbA1c) | Quarterly coverage for stable diabetics; more frequent testing supported only with a documented treatment change. ICD-10 Z-codes are not covered diagnoses. |
| L35095 | Vitamin D Assay | Coverage requires a documented deficiency or at-risk condition (E55.x, M81.0, malabsorption). Routine screening billed under a Z-code diagnosis is denied. |
| L35396 | Tumor Markers — PSA (84153), CEA (82378), CA-125 (86304) | Each carries its own ICD-10 requirements and is not covered for screening in asymptomatic patients. |
| L35471 | Lipid Testing | Annual screening coverage under Z13.220. Quarterly testing supported only for patients with documented dyslipidemia on treatment. |
| L35099 | Laboratory Testing for Non-Covered Services | An ABN is required before performing any test not expected to be covered. |
| Test | CPT | Frequency Limit |
|---|---|---|
| HbA1c | 83036 | Every 3 months for stable diabetics; monthly for newly diagnosed or treatment-change patients |
| Lipid Panel | 80061 | Once per year for screening; quarterly for treatment monitoring |
| Vitamin D | 82306 | Once per year unless documented therapeutic monitoring |
| PSA | 84153 | Once per year for monitoring known prostate cancer; not covered for screening |
| Basic Metabolic Panel | 80047 | No fixed limit — medical necessity must be documented |
HbA1c frequency violations — billing outside the quarterly window without a documented treatment change.
HbA1c frequency violations — billing outside the quarterly window without a documented treatment change.
Vitamin D without supported ICD-10 — screening diagnoses billed against a rule that requires documented deficiency.
Molecular Z-Code compliance — an emerging review area given confirmed MolDX participation in this jurisdiction.
| Area | Requirement |
|---|---|
| Provider Enrollment | Independent labs enroll via CMS-855B; hospital outpatient labs via CMS-855A. Both submit to the WPS enrollment unit in Madison, WI. |
| ABN Requirements | Have an ABN workflow ready for any test with frequency limits, ICD-10 restrictions, or any molecular test without a confirmed Z-Code. WPS uses the standard CMS-R-131 form. |
| CLFS / Fee Schedule | WPS applies annual CLFS rate updates effective January 1. Audit contracted rates against the current CLFS at every annual update. |
Labs lose revenue to preventable denials; miscoded panels, missed modifiers, payer-specific mismatches. TransLabs built its billing process around what labs actually need to get paid, coast to coast. Start with a complimentary claims audit. We’ll review your CPT/HCPCS coding, test methodology, and denial trends to show you exactly what’s recoverable.
Claims checked against your MAC's local coverage rules before submission.
Medicaid and commercial prior-auth rules built into your workflow, not discovered after denial.
Appeals strategy built from denial data across all 50 states.
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Yes. J5, administered by WPS, is a MolDX jurisdiction. Labs billing molecular diagnostic tests in the 81XXX range or most PLA codes must hold an active DEX Z-Code from Palmetto GBA before submitting claims.
The claim is denied automatically. There’s no manual override at the claims level, which is why Z-Code registration has to happen before billing.
Iowa, Kansas, Missouri, and Nebraska. WPS processes J5 (and J8) claims through the Mediweb portal.
Quarterly for stable diabetic patients under LCD L35062. More frequent billing needs documentation of a treatment change or new diagnosis; ICD-10 Z-codes aren’t a covered diagnosis for this test.
CMS has proposed merging J5 with J6 into a new “Jurisdiction G,” with no confirmed implementation date as of the most recent review. Reverify current status at cms.gov.
CMS-855B for independent labs, submitted to the WPS enrollment unit in Madison, Wisconsin. Hospital outpatient labs use CMS-855A instead.
