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eviCore Molecular and Genomic Testing Program

July 30, 2017

Effective August 1, 2017, Horizon Blue Cross Blue Shield of New Jersey has implemented a new specialty utilization management program in collaboration with eviCore healthcare (eviCore) for certain molecular and genomic diagnostic laboratory testing services. This 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, known as Horizon BCBSNJ’s Molecular and Genomic Testing Program, eviCore will conduct pre-service Medical Necessity Determination (MND) reviews of certain molecular and genomic diagnostic testing services that are rendered in a physician’s office or clinical laboratory setting.

This new process focuses on ensuring your employees and their covered dependent(s) receive the right care at the right time. Through the Molecular and Genomic Testing Program, eviCore will conduct pre-service MND reviews of certain molecular and genomic tests to:

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

If your employees or their 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 beginning August 1, 2017 and after, for which no pre-service MND is obtained, may be delayed while information for eviCore to conduct post-service MND is requested and reviewed.

About the eviCore 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. These can include:

  • Pre- and post-service MNDs
  • First level appeals of UM denials
  • Claims processing

If you have questions, please reach out to your Horizon BCBSNJ contact.

Published on: July 26, 2017, 07:01 a.m. ET
Last updated on: July 26, 2017, 07:12 a.m. ET