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Last year, AmeriHealth introduced a new utilization management program for
genetic/genomic tests, certain molecular analyses, and cytogenetic tests for
all commercial members. We are working with CareCore National, LLC d/b/a
eviCore healthcare (eviCore), a specialty benefit management company, to manage
precertification and/or prepayment coverage reviews for these tests.
To view the full list of tests that require precertification, you can access
the Prior Authorization Procedure Lists for AmeriHealth New Jersey and AmeriHealth Pennsylvania.
Please note that the ordering provider or laboratory is responsible for
submitting precertification requests for the applicable tests. Failure to
adhere to the precertification process may result in your AmeriHealth members
assuming financial responsibility and receiving a high-cost bill for the
testing.
Precertification process
Ordering health care providers must contact eviCore to obtain
precertification for certain genetic/genomic tests, including, but not limited
to, the following:*
- BRCA gene testing
- genetic panels and cancer gene expression tests
- genome-wide tests
- pharmacogenomic tests
You can initiate precertification for genetic/genomic tests in one of the
following ways:
- NaviNet® web portal. Select CareCore from the
Authorizations option in the AmeriHealth Workflows menu.
- Telephone. Call eviCore directly at 1-866-686-2649.
Important information for laboratories
When a request for certain genetic/genomic testing is received, laboratories
must ensure a precertification is on file before rendering services. If a
precertification is not on file for the member, it is the laboratory?s
responsibility to go through the above precertification process through
eviCore.
Prepayment review
All genetic/genomic tests, along with certain molecular analyses and
cytogenetic tests, are reviewed by eviCore prior to final claim adjudication
and payment (if applicable). Examples of molecular analyses and cytogenetic
tests include, but are not limited to, the following:*
- flow cytometry
- fluorescent in situ hybridization (FISH)
- immunohistochemistry (IHC)
- karyotyping
- morphometric analyses
Lab management policy and guidelines
Review Medical Policy #06.02.52f: eviCore Lab Management Program for more
information about the utilization management program. The policy includes a
link to the Lab Management Program Clinical Guidelines that eviCore
uses during the precertification and prepayment review processes, as well as a
listing of procedure codes requiring precertification and/or prepayment
review.
To view this policy, visit our Medical Policy Portal.
Select Accept and Go to Medical Policy Online, then select the
Commercial tab from the top of the page and type the policy name or
number in the Search field.
More information
If you have questions about any of these requirements, call Customer Service
at 1-888-YOUR-AH1 for AmeriHealth New Jersey or at 1-800-275-2583
for AmeriHealth Pennsylvania.
*This list of services is subject to change.
NaviNet is a registered trademark of NaviNet, Inc.
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