Doctor Patel in the lab

Pre-Authorization Information

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