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 81479

 

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.
Aetna EviCore www.evicore.com 866-686-2649
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)
EviCore www.evicore.com 866-686-2649
CIGNA EviCore www.evicore.com 866-686-2649
Excellus BCBS EviCore www.evicore.com 866-686-2649
Highmark BCBS EviCore www.evicore.com 866-686-2649
Humana Humana www.humana.com/providers 800-523-0023
Oscar EviCore www.evicore.com 866-686-2649
Passport Health Plan EviCore www.evicore.com 866-686-2649
United Healthcare Beacon www.uhcprovider.com 877-842-3210
WellCare EviCore www.evicore.com 866-686-2649