For billing offices: a lab medical-necessity lookup that answers in one screen
You have a lab order and a claim. You need to know, right now, whether the diagnosis on it makes the test pay under Medicare, how often the rule allows it, and what to cite if it does not. We are building that, for the 23 national laboratory rules, and we want to know whether you would use it.
What it does
- Enter a test code and a diagnosis code. Get a yes or no against the national rule, in plain words, with the rule cited.
- Or enter the test code alone. Get the full list of diagnosis codes the rule accepts, with their names, not a spreadsheet of bare codes.
- Frequency limits stated the way the rule states them, so a "too frequent" denial is not a surprise.
- The ABN reason ready to copy, in CMS's own wording, when the answer is no.
- Batch mode for a day's orders: paste the pairs, get the answers back in one table.
- Nothing to install, nothing stored. Codes only; no patient information is ever entered, so there is nothing to protect.
Where the answers come from
The 23 national laboratory coverage determinations (NCD Manual sections 190.12 through 190.34) are the only Medicare rules that come with a machine-readable list of the diagnosis codes that satisfy them. CMS updates that list every quarter. ClaraCover keeps a checked copy of every list, the current Clinical Laboratory Fee Schedule, and the diagnosis-code names, and applies them the same way the claims system does. For what that rule is and why lab tests are the one place a straight answer exists, see what Medicare means by "reasonable and necessary."
The same data already runs the free pages on this site: every test page shows the rule, the covered diagnoses in plain English, and the fee schedule amount. The billing-office version adds the full lists, the batch check, and no daily limit.
What it will cost
We have not set a price. It will be a small monthly subscription for a single seat, cancel any time, and the free pages stay free for everyone. If you tell us what you would pay for, that shapes what we build first.
Questions we expect
Does it cover local coverage determinations? The first version covers the 23 national laboratory rules, which are the same in every state. Where a test has no national rule, it says so and names the general standard, so you know to check your contractor's LCD.
Is it a substitute for the Medicare Coverage Database? No. It is the same public rule, read faster. The database stays the authority, and every answer links to it.
Is it for patients or for offices? Both, in different forms. Patients get the free pages. Offices get the lists, the batch check, and the volume.
Want it? Leave your email at the top of the page.
ClaraCover is an independent publisher of Medicare coverage information and is not affiliated with Medicare, CMS, or any Medicare contractor. Answers describe published Medicare rules and are not billing, coding, legal, or medical advice; the claim and its coding remain the provider's responsibility.