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Molecular and Genomic Testing Program Update

Effective January 15, 2018, additional diagnostic tests will be included as part of our Molecular and Genomic Testing Program, administered by eviCore healthcare (eviCore) for members enrolled in Horizon BCBSNJ fully-insured products as well as administrative services only (ASO) accounts that have elected the Molecular and Genomic Testing Program.

Beginning with services to be provided on and after January 15, 2018, eviCore will conduct pre-service Medical Necessity Determination (MND) reviews of the following additional diagnostic testing services (recently published by the American Medical Association) when rendered in a physician’s office or clinical laboratory:1

  • 0026U
  • 0028U
  • 0029U
  • 0030U
  • 0031U
  • 0032U
  • 0033U
  • 0034U
  • 81230
  • 81231
  • 81232
  • 81238
  • 81249
  • 81257
  • 81259
  • 81269
  • 81283
  • 81328
  • 81335
  • 81346
  • 81361
  • 81363
  • 81364
  • 81448
  • 81520
  • 81521
  • 81541
  • 81551

Review the complete list of molecular and genomic diagnostic testing services that require pre-service MND reviews.

Additionally, the following diagnostic testing services no longer require pre-service MND review:

  • 0008M

For more information about this specialty utilization management program, visit our Molecular and Genomic Testing Program web page. If you have questions, please contact your Network Specialist or Ancillary Contracting Specialist.

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).

CPT® is a registered trademark of the American Medical Association.


Pre-service MND reviews

To obtain pre-service MND from eviCore (or to validate that a pre-service MND was requested and/or approved):

  • Visit.eviCore.com; or
  • Call 1-844-224-0493, between 7 a.m. and 7 p.m., Eastern Time.

The guidelines eviCore uses to conduct MND reviews for the Molecular and Genomic Testing Program may be reviewed online at www.evicore.com/healthplan/Horizon_Lab.

Published on: December 18, 2017, 15:52 p.m. ET
Last updated on: December 18, 2017, 16:03 p.m. ET