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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.

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).

Approved requests

When your authorization is approved, AIM ProviderPortal will indicate it’s "Authorized" in the Order Request Preview (see  in the example below) You’ll also find:

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

Please be sure to:

  • Tell the member that they must have the test within the timeframe approved (see  in example). Otherwise, if the test is outside of those dates, a new authorization request will be needed.

  • Attach a copy of the approved authorization to your lab requisition form. This will help the lab understand what's been approved. You’ll be able to download a PDF or print a copy (see  in example) after you have submitted your authorization request and it’s been approved.
    • Click "View Details" ( in example) to see all CPT codes associated with the test that are approved. Remember: You will need to make sure you have approval for each CPT code.

Important: We recommend attaching a copy of the approved authorization to your lab requisition instead of using a pre-populated lab requisition form, such as the one in the example below. When you enter the test into AIM’s ProviderPortal, you are requesting the individual test, not a panel, so the test authorized and the pre-populated form are not always a match.

 

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).

Information for servicing laboratories

When a specimen comes into your lab for genetic testing, before you analyze the specimen, please remember to verify:

  • An approved authorization for the test. You can verify the authorization approval by going to the AIM ProviderPortal.
  • The CPT codes approved as part of that authorization. Next, you can give those codes to your billing department for your claim, so your claims will process smoothly.
    • Click "View Details" (See  in the example above) to see any CPT codes associated with the test that are approved.
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

We use AIM clinical criteria to make medical necessity determinations. Refer to our medical policy 954 for links to AIM’s criteria.

Blue Cross continues to maintain medical policies for the following:

  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).
  3. Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy): 797. We maintain the criteria, but prior authorization should be requested through AIM.
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