Cologuard^™, a stool-based colorectal cancer screening test, and non-invasive prenatal testing/screening (NIPT/NIPS) currently require precertification by AmeriHealth for all commercial members. In addition, CareCore National, LLC d/b/a eviCore healthcare (eviCore) manages the prepayment review for these services on our behalf.

Effective October 15, 2016, the following changes will apply:

• Cologuard^™: Precertification will no longer be required by AmeriHealth. In addition, eviCore will no longer manage the prepayment review for this service. However, providers are still responsible for ensuring that the individual?s medical record reflects the medical necessity criteria for this service.
• – The Current Procedural Terminology (CPT^®) and Healthcare Common Procedure Coding System (HCPCS) codes
  that represent Cologuard^™ are 81528 and G0464.
• NIPT/NIPS: Precertification will no longer be required by AmeriHealth. However, eviCore will continue to manage the prepayment review for this service.
• –The CPT codes that represent NIPT/NIPS are 81420, 81507, and 0009M.

Precertification list update and medical policy changes

As a result of Cologuard^™ and NIPT no longer requiring precertification, our updated precertification requirement lists will be available later this month for AmeriHealth New Jersey and for AmeriHealth Pennsylvania.

The following text will be removed from the genetic and genomic tests requiring precertification section:

• Stool-based colon cancer screening (Cologuard^™)
• Non-invasive prenatal testing for Down syndrome and other common chromosome abnormalities (such as Harmony^™, informaSeq^®, Informed Pregnancy Screen, MaterniT21^®, Panorama^®, verifI^®)

In addition, Medical Policy #06.02.52a: eviCore Lab Management Program will be modified to reflect the change in utilization management for these services. The updated policy will be posted to the Medical Policy Portal on October 17, 2016. To view this policy after October 17, 2016, select Accept and Go to Medical Policy Online, then select Commercial, and type the policy name or number in the Search field.

If you have questions about any of these changes, you can contact your Provider Partnership Associate or Network Coordinator.

CPT copyright 2015 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.