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Genetic Testing

Depending on the member’s plan, we may require prior authorization or prior approval for genetic testing.

For these members Authorization (or prior approval) is required Who to contact for prior authorization (or prior approval)
Commercial HMO/POS members who have a Massachusetts PCP
(including New England Health Plan members)
Yes (for most tests – see below) AIM Specialty Health®‵
Commercial PPO/EPO plan members Yes (for most tests – see below) AIM Specialty Health
Federal Employee Program members Yes (some tests) Blue Cross Blue Shield of Massachusetts Clinical Intake department at 1-800-689-7219
Medicare Advantage Please see the appropriate National Coverage Determination (NCD) or Local Coverage Determination (LCD) through the CMS website for specific genetic testing guidelines

Prior authorization program with AIM Specialty Health
For members requiring prior authorization with AIM (see the table above), here’s some information about the program.

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Which genetic testing services require prior authorization with AIM Specialty Health?

As always, we recommend checking benefits and eligibility to determine the member’s benefits and any authorization requirements before performing services.

Refer to AIM Genetic Testing Management Program CPT and HCPCS Codes medical policy 957.

Categories of tests that require prior authorization include, but may not be limited to:

  • Genetic testing for hereditary risk of cardiac disease
  • Genetic testing for hereditary cancer susceptibility
  • Genetic testing for single-gene and multifactorial conditions
  • Pharmacogenetic and thrombophilia genetic testing
  • Reproductive carrier screening and prenatal diagnosis
  • Solid and hematologic tumor and malignancy testing
  • Whole exome and genome sequencing

Prior authorization is not required for genetic testing associated with organ transplantation.

For preimplantation genetic testing, we don’t require prior authorization with AIM; however, you should continue to request prior authorization from Blue Cross Blue Shield of Massachusetts for biopsy of the embryo. Refer to our medical policy, Preimplantation Genetic Testing: 088.

How to request prior authorization with AIM Specialty Health

Ordering physicians or clinicians must request authorization before the member receives the test (or before performing services). There are three ways to contact AIM to request prior authorization:

  1. Through a direct link on this site (no additional registration is required). In the eTools tab, go to AIM Specialty Health(). Click the Go Now button.
  2. Go directly to the AIM ProviderPortal (registration is required) Note: If you’ve already registered for the AIM ProviderPortal for Blue Cross Blue Shield of Massachusetts or another insurer, you won’t need to register again.
  3. Call AIM’s Contact Center at 1-866-745-1783
    • Available Monday through Friday, 8 a.m. – 6 p.m. If you leave a voicemail after these hours, AIM will respond the next business day.
Information to have ready

Here’s some general information you may need to request the authorization. You can find checklists for specific tests on the AIM genetic testing program site at: http://www.aimproviders.com/genetictesting/Resources.html

  • Member’s first and last name, date of birth
  • Summary of the patient’s clinical diagnosis
  • Ordering provider’s first and last name
  • Clinical summary from the genetic counseling appointment
  • Test being requested and the name of the laboratory performing the test (you’ll be able to choose the test from a menu that includes branded panels, or you can manually enter it)
  • Pedigree or summary of three-generation maternal and paternal family history
  • Maternal and paternal ethnic background/race

Tips for entering the date of service for the test
The date of service is the estimated date that the laboratory is likely to begin the testing process.

It is not the date the sample is collected, unless the test is being performed on the same date the sample was collected.

The ordering provider may not know the exact date that a test will be performed. A reasonable estimate of one to three days in the future will cover the vast majority of genetic testing performed.

Getting an authorization decision (online)

Once the ordering physician, clinician, or their office staff has entered the required information into the online authorization tool, you’ll get an immediate decision (in most cases). If AIM needs more time to review the information, the system will indicate that it’s pending review. And, if AIM needs more information for their review, you’ll get a request to submit additional information.

When your authorization is approved, you’ll see:

  • The name of the approved test & CPT code(s)
  • The units approved

We recommend printing or downloading a copy to include with the lab requisition.

Please note: When you request prior authorization, it's for a specific genetic test. You aren't requesting prior authorization for the CPT code(s).

Servicing laboratories can verify authorizations online
If you are a servicing laboratory, you can go onto the AIM ProviderPortal to verify the member has an approved authorization. Laboratories can also access a report of all authorizations requested through the portal for their laboratory.

Matching an approved authorization with the claim

We’re matching the approved CPT codes and unit amounts to the claim that the laboratory submits. If these fields don’t match, the claim will deny. To avoid a denied claim, we urge clinical and hospital laboratories to use the AIM ProviderPortal to verify that an authorization is in place before the test is performed. We suggest sharing the authorization approval information (CPT codes and units) with your billing department.

Clinical criteria used to make a medical necessity determination

AIM will use its own clinical criteria to make a medical necessity determination. We will link to their clinical criteria from our medical policy. Our existing medical policies for genetic testing will be replaced by AIM’s clinical criteria. There are two exceptions:

  1. Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies: 790, for which we will continue to maintain the criteria and AIM will administer prior authorization decisions.
  2. Preimplantation Genetic Testing: 088, for which the biopsy of the embryo will continue to require prior authorization directly from Blue Cross Blue Shield of Massachusetts, but the associated genetic testing does not require prior authorization if performed for preimplantation genetic diagnosis (as opposed to screening).
Resources

 Answers to frequently asked questions (FAQs) about the genetic testing prior authorization program

 Webinar slide deck

 Webinar slide deck (log in to download)

AIM also offers information on its resource website, http://www.aimproviders.com/genetictesting/Resources.html. You’ll find:

  • Program information & clinical guidelines
  • Tutorials (on how to enter an authorization using the AIM online tool)
  • Worksheets to help your office prepare the information needed to enter the authorization request