Important PECOS Reminder
The Centers for Medicare and Medicaid (CMS) require all providers (e.g., physicians, non-physicians and dentists) who order and refer tests or services for Medicare beneficiaries to be enrolled in PECOS. Claims (your own as well as the receiving laboratory’s) will be denied if the ordering/referring provider is not enrolled in PECOS.
The following link may be referred to for additional information and enrollment:
ProPath appreciates your attention to this matter so any services, including your own, ordered, referred and billed for a Medicare beneficiary is processed accordingly without delay.
If ProPath is denied payment due to non-enrollment, the client could be billed for the services rendered.
ProPath is a participating provider with most insurance companies. Please see your sales or service representative for a complete insurance list.
How to Designate Physician Billing
If the physician would like to be billed for a particular patient’s testing, please check “ACCOUNT” under the “BILL TO” section of the requisition or online order form. Each client is billed once a month with an itemized invoice. Payment is due within thirty (30) days.
NOTE: Most states have laws/regulations addressing direct or pass-through billing. Health Plans also have contractual language and policies also related to this practice. Hospital-registered patients who are covered by a governmental plan (e.g. Medicare/Medicaid/Tricare) must have technical charges billed to the hospital/client as these services are reimbursed to the facility under the prospective payment system (PPS) or outpatient prospective payment system (OPPS).
For questions about your client invoice,
call 214-237-1665 or 800-654-1888 ext. 1665, Fax 214-631-6724
M-F 8:00 a.m. – 4:30 p.m. C.S.T.
How to Designate Patient Billing
If the patient is self pay, please check “PATIENT” under the “BILL TO” section of the requisition or online order form. Please be sure to provide complete patient name, address, city, state, ZIP code, and telephone number. For uninsured patients, please contact your sales or service representative to learn about our Uninsured Billing Policy.
Billing to Medicare/Medicaid
ProPath is required to bill Medicare for all patients enrolled under Part B, when Medicare covers the testing services performed. For tests not covered by Medicare (e.g., some routine Pap screening), an ABN (Advanced Beneficiary Notice) must be completed by the physician’s office and signed by the Medicare patient.
ProPath will also bill Medicaid as required.
The minimum information required for billing Medicare and Medicaid is as follows:
- Patient Name
- Patient Address
- Patient Date of Birth
- Patient Sex
- Medicare/Medicaid Number
- Referring Physician
- Referring Address
- ICD-10 Code
- NPI Number
To Designate Third Party Billing
ProPath is contracted with many insurance carriers. Please fill in the appropriate information on the test requisition (i.e., HMO, PPO, Medicare, etc.).
A copy of your office face sheet and the front and back of the patient’s insurance card will ensure accurate billing.
NOTE: Due to the fact that most insurance carriers allow only a short filing deadline, sufficient data to properly bill the third party carrier is imperative. ProPath will attempt to contact the physician’s office for any missing information. If unsuccessful, the patient will be billed directly.
Making a Payment
ProPath accepts VISA and Mastercard, checks and ACH (wired) payments. Please be sure to reference your Invoice Number when making a payment.
Payments by credit card can be made by calling our Client Billing office at (214) 237-1665 or (800) 654-1888 and ask for Client Billing.
Terms are Net 30 days.
Prior Authorization Payer Requirements for Molecular/Genetic Testing
Many payers have implemented new prior authorization requirements related to Molecular and Genetic Testing. It is important for you to be aware of these requirements and obtain the appropriate prior authorization from your patient’s insurance plan BEFORE ordering the testing when appropriate.
To assist in this process, ProPath has created this information to explain which Molecular testing ProPath offers that may fall under these payer requirements. Each payer has different requirements and processes, so it is important for your office to become familiar with each plan’s guidelines when ordering Molecular testing.
Please note that ONLY THE ORDERING CLINICAL PROVIDER IS ALLOWED TO SUBMIT THE PRIOR AUTHORIZATION. Unfortunately, labs are not able to obtain prior authorizations on behalf of the ordering provider.
Starting November 1, 2017, United Healthcare (UHC) implemented their Prior Authorization and Notification program for Genetic and Molecular Lab Testing. This requirement applies to the UHC Commercial Benefits Plan.
Ordering providers will be able to complete the prior authorization process online. The online prior authorization and notification process will give providers a quick coverage determination when their requests for these tests meet UHC clinical guideline criteria.
Providers can access UHC Prior Authorization and Notification forms and instructions online at uhcprovider.com and either choosing “Prior Authorization and Notification” from the Menu icon or by clicking on the LINK icon in the top left corner (where you will be prompted to log in).
What does this mean for you and your patient?
ProPath may not perform diagnostic testing on specimens received without documentation of a completed prior authorization and notice. If the authorization information is not provided, we will contact your office before performing the requested testing to request this authorization be completed. If the notice is not obtained, ProPath may not be able to perform the testing.
To learn more about the Genetic and Molecular Lab Testing Prior Authorization and Notification programs, please visit payers’ websites listed below.
Thank you for your assistance in complying with these new requirements.
|ProPath Molecular Testing||CPT Code|
|BCR/Abl; Major breakpoint||81206|
|BCR/Abl; Minor breakpoint||81207|
|BRAF Gene Analysis (eg, colon cancer)||81210|
|CALR (Calreticulin) Gene Analysis||81219|
|CF Cystic Fibrosis||81220|
|EGFR (epidermal growth factor receptor) Gene Analysis (eg, non-small cell lung cancer)||81235|
|FLT3 (fms-related tyrosine kinese 3) Gene Analysis (eg, acute myeloid leukemia)||81245|
|IGH (immunoglobulin heavy chain locus) Gene Analysis (eg, leukemia and lymphoma, B-cell)||81261|
|JAK2 (Janus kinase 2) Gene Analysis (eg, myeloproliferative disorder)||81270|
|KRAS (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) Carcinoma Gene Analysis||81275|
|KRAS (Kirsten rat sarcoma viral oncogene homolog) Carcinoma Gene Analysis||81276|
|MSI (Microsatellite instability) Gene Analysis (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome)||81301|
|NRAS (neuroblastoma RAS viral [v-ras] oncogene homolog) Gene Analysis||81311|
|TRG (T cell antigen receptor, gamma) Gene Rearrangement Analysis (eg, leukemia and lymphoma)||81342|
|MPL Gene Analysis (eg, myeloproliferative disorder)||81402|
|JAK2 (Janus kinase 2) Gene Analysis (eg, myeloproliferative disorder)||81403|
|PIK3CA (Phosphatidylinositol-4.5-bisphosphate 3-kinase, catalytic subunit alpha) Gene Analysis||81404|
|MYD88 (Myeloid differentiation primary response gene 88) Gene Analysis||81|
|Payer Preauthorization Contacts||Administrator||Website||Phone:|
|Please note: This is only a partial list. Please check with the patient’s health plan to ensure services will be covered.|
|Ambetter||Superior Health Plan||www.superiorhealthplan.com/providers/preauth-check/ambetter-pre-auth.html||877-687-1196|
|Blue Cross Blue Shield
(TX, OK, LA, NM, IL, MT, AL)
|Passport Health Plan||EviCore||www.evicore.com||866-686-2649|