UnitedHealthcare Commercial Member Coverage: Genetic & Molecular Testing

UnitedHealthcare will implement a national online prior authorization program for genetic and molecular testing performed in an outpatient setting effective Oct. 1, 2017 for fully insured UnitedHealthcare Commercial members. During the authorization process, care providers will indicate the laboratory name, test name or gene. Clinical information will be requested to determine if the request meets  UnitedHealthcare’s clinical policy requirements for coverage. It will be the participating laboratory’s responsibility to determine if an authorization has been received as services rendered without an authorization will be denied and the member cannot be balance billed. If an authorization has not been granted, the participating laboratory staff should contact the ordering provider to request a prior authorization. Laboratories that perform genetic or molecular testing will be asked to provide details on their genetic and molecular tests (i.e., test name, test ID number, codes used for billing, etc.) starting in second quarter 2017. This information will be required for UnitedHealthcare to complete an authorization and to ensure correct coding and payment of claims. When the program is implemented, United Healthcare will only authorize payment for those CPT codes that have been registered with the Genetic and Molecular Testing Prior Authorization Program for each specified genetic test. Laboratory services ordered by Florida and Texas network providers for fully insured UnitedHealthcare Commercial members in Florida and Texas will not be required to participate in this requirement due to their participation in the UnitedHealthcare Laboratory Benefit Management Program.

Source: https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/News/June-Interactive-Network-Bulletin-2017.pdf