Idaho Medicaid coverage includes laboratory and pathology services performed in a credentialed lab, but only when such testing is considered under current standards to be reasonable and necessary for the diagnosis and potential treatment of an illness, disease, or condition. Screening services are covered as mandated by the Affordable Care Act (ACA) and recommended by the US Preventive Services Task Force (USPSTF) with an “A” or “B” recommendation, or when listed in the American Academy of Pediatrics Bright Futures periodicity schedule.
The following types of laboratory and pathology services are not covered by Idaho Medicaid:
Tests performed for screening purposes only, in the absence of signs, symptoms, or personal history of disease or injury without an “A” or “B” recommendation from the USPSTF or on the Bright Futures periodicity schedule.
Tests that are done solely to diagnose a patient, and will not impact medical decision-making for the patient or the patient’s treatment plan.
Tests performed for the purposes of genetic counseling or family planning.
Tests that do not meet the definition of medical necessity as set forth in IDAPA 16.03.09.011.16.
Assistance for Providers
The Numerical Fee Schedule shows which labs always require a prior authorization, and which organization will review your request.