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Horizon BCBSNJ’s Molecular and Genomic Testing Program

July 19, 2017

Applies to: All markets, excluding FEP, SHBP/SEHBP, Medicare Advantage, Medigap, Medicaid and DSNP

Beginning August 1, 2017, Horizon Blue Cross Blue Shield of New Jersey will implement a new specialty utilization management program in collaboration with eviCore healthcare (eviCore) for certain molecular and genomic diagnostic laboratory testing services. This Horizon BCBSNJ Molecular and Genomic Testing Program applies to Horizon BCBSNJ members enrolled in fully insured products, and Administrative Services Only (ASO) accounts that have elected to participate in the Molecular and Genomic Testing Program.

Through this collaboration, eviCore will conduct pre-service Medical Necessity Determination (MND) reviews of certain molecular and genomic diagnostic testing services that are rendered in a doctor’s office or clinical laboratory setting1.

This new program focuses on ensuring your clients and their employees receive the right care at the right time. The pre-service MND reviews will:

  • Determine medical necessity; and
  • Help ensure the testing is performed by an appropriately qualified Horizon BCBSNJ participating laboratory provider whenever possible

This program does not apply to the Federal Employee Program® (FEP®), the State Health Benefits Program (SHBP), the School Employees' Health Benefits Program (SEHBP), Medicare Advantage, Medigap, Medicaid or Dual-Eligible Special Needs (DSNP) plans.

If your clients and/or their employees and covered dependent(s) may need molecular and/or genomic diagnostic laboratory testing services, they should ask their doctor to request a pre-service MND review prior to the test being performed. Claims for molecular and genomic diagnostic laboratory testing services that are provided on and after August 1, 2017, for which no pre-service MND is obtained, may be delayed while eviCore conducts a post-service MND.

1 MND requirements will not apply to molecular and genomic diagnostic testing services rendered to patients in a hospital Emergency Room (ER), hospital outpatient or inpatient setting, or an Ambulatory Surgery Center (ASC).

About the Horizon BCBSNJ Molecular and Genomic Testing Program

Molecular and genomic testing are laboratory services that include:

  • Hereditary Cancer Screening
  • Carrier Screening
  • Tumor marker/molecular profiling
  • Hereditary cardiac disorders
  • Cardiovascular disease and thrombosis risk variant testing
  • Pharmacogenomic testing
  • Neurologic disorders
  • Mitochondrial disease testing
  • Intellectual disability/developmental disorders

Horizon BCBSNJ collaborates with eviCore to manage certain molecular genetic diagnostic testing services, including MND review for non-emergent molecular genetic diagnostic testing services. These can include:

  • Pre- and post-service MNDs
  • First level appeals of Utilization Management (UM) denials
  • Claims processing

If you have an ASO group client, your Horizon BCBSNJ sales executive or account manager will contact you about this program.

If you have questions, please contact your Horizon BCBSNJ sales executive or account manager.

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Published on: July 26, 2017, 05:30 a.m. ET
Last updated on: April 26, 2021, 01:37 a.m. ET