Payment Integrity Programs to Launch Throughout 2026
What is payment integrity?
Payment integrity is an ongoing effort to ensure that healthcare claims are processed accurately, fairly, and in accordance with established policies. By reviewing claims for correct coding, billing, and clinical appropriateness, payment integrity programs help prevent errors, reduce unnecessary costs, and protect members from risks associated with improper or excessive medical services.
In 2026, Premera is introducing a new Routine Test Management (RTM) program. Premera will work with Avalon Healthcare Solutions to execute this new program. RTM helps members receive high-quality services at the most affordable price.
RTM includes laboratory policies based on the latest science and clinically accepted, peer-reviewed laboratory services guidelines.
Why it matters
More than 14 billion lab tests are performed in the U.S. each year, making it the most used medical benefit. Without clear standards, tests can be misinterpreted or misused, putting members at risk. Unnecessary tests may lead to extra sample collection, false results, and unnecessary treatments. RTM ensures members get only the tests they need, reducing risks from extra procedures.
How it works
Claims are reviewed after service but before payment. Automated tools check for:
- Procedures that can’t be done together
- Limits on frequency and units
- Age and clinical appropriateness
- Required add-on procedures
Tests from ER, hospital stays, or observation settings are excluded from review.
What you need to know
- New and revised policies that impact certain laboratory services, tests, and procedures will be published later this year.
- Consistent enforcement of laboratory policies will occur through automated claim editing for select laboratory tests performed in office, hospital outpatient, and independent laboratory locations.
- Laboratory services, tests, and procedures provided in the emergency room, hospital observation, and hospital inpatient settings are excluded from this program.
Who’s impacted by the new program
- All funding types
- All group sizes
We appreciate your patience as we make this important transition.