Medicare's date of service (DOS) rule for laboratory tests - often given the name, "14 day rule" - gets a new spin in a publication from United Healthcare affecting millions of beneficiaries.
Thanks to Ashley Zarling for highlighting the event at LinkedIn.
CMS Date of Service. Since about 2001, CMS has set the "date of service" rule for lab tests - both clin lab & pathology - as teh date of specimen collection, and separate rules (not the DOS regulation itself) often lead to hospital inpatient and outpatient lab tests being bundled and not separately payable. CMS bundles all inpatient lab tests, even those ordered 13 days after hospital discharge, to the hospital inpatient DRG, and CMs bundles most lab tests for outpatients to hospital outpatient events like office or ER visits, tagging them with a "status indicator" for bundling or, rarely, separate payment. 42 CFR 414.510 See also an explanatory webpage at CMS.
Medicare Advantage plans don't have to follow this rule, although I suspect they usually do, and other commercial insurance plans definitely don't have to follow this rule - but they may often elect to, by stating that as a first principle, Medicare billing rules will be followed.
New Rule at United Healthcare
The new rule at United Healthcare was published May 1, 2026, as new "Question 9" of document 2026R0111B, rules for submitting a 1500 claim form. United states that, "This reimbursement policy applies to all health care services billed on CMS 1500 forms and, when specified, to those billed on UB04 forms."
The rules have a number of entries about United's use of MolDx and Z-codes.
Q: Which date should be submitted on the claim for reflex testing?
A: According to CMS, when reflex testing is performed, the date of service (DOS) submitted for each test must be the date the reflex test itself is performed, not the date the original specimen was collected.
I'm not sure exactly where United gets this rule from ("Accoding to CMS..."). United has a blanket reference for all its rule, referring to CMS, CMS Manuals, or Other CMS Publications.
Without knowing a written exception, I would have said the date of reflex testing would generally be the date of specimen collection - the master CMS rule for DOS, unless the test was ordered > 14 days after inpatient or outpatient discharge.
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See a "deep dive" AI written research article on DOS back to the 1990s, here.
