Home Administrative Billing & Reimbursement Health and Wellness Medical PEAR portal Pharmacy Products Quality Management

Reminder: Utilization management program for genetic/genomic tests, certain molecular analyses, and cytogenetic tests

September 21, 2017

[

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.

]

This content was prepared for the Provider News Center and may not be reproduced in any way without the express written permission of AmeriHealth, AmeriHealth HMO, Inc., AmeriHealth Insurance Company of New Jersey.
© 2023 AmeriHealth Site Map        Anti-Fraud        Privacy Policy        Legal        Disclaimer