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.
As always, we recommend checking benefits and eligibility to determine the member’s benefits and any authorization requirements before performing services.
Categories of tests that require prior authorization include, but may not be limited to:
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.
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:
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
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.
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:
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.
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.
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:
Answers to frequently asked questions (FAQs) about the genetic testing prior authorization program
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AIM also offers information on its resource website, http://www.aimproviders.com/genetictesting/Resources.html. You’ll find: