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New review process for certain molecular and genomic diagnostic laboratory testing services

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.

Through this collaboration, which will be 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 the following settings1:

  • Physician’s office
  • Clinical laboratory

This new process focuses on ensuring you 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 you or a covered dependent may need molecular and/or genomic diagnostic laboratory testing services, you should ask your 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.

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

Published on: July 7, 2017, 14:13 p.m. ET
Last updated on: July 7, 2017, 14:15 p.m. ET