Skip to main content

Molecular and Genomic Testing Program Update: February 2021

Horizon BCBSNJ will implement changes to the services 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 participate in the Molecular and Genomic Testing Program.

For services to be rendered on and after February 1, 2021 in a physician’s office or clinical laboratory, eviCore will also conduct pre-service Medical Necessity Determination (MND) reviews of the services represented by the following Proprietary Laboratory Analyses (PLA) codes:

  • 0228U
  • 0229U
  • 0230U
  • 0231U
  • 0232U
  • 0233U
  • 0234U
  • 0235U
  • 0236U
  • 0237U
  • 0238U
  • 0239U
  • 81351
  • 81353
  • 81419
  • 81529
  • 81546
  • 81554

Effective for services to be provided after December 31, 2020, eviCore will no longer conduct pre-service MND reviews of the services represented by the following procedure codes as part of this program.

  • 81401
  • 81402
  • 81403
  • 81404
  • 81405
  • 81545

Review the complete list of molecular and genomic diagnostic testing services subject to MND review as part of this program or review more details about our Molecular and Genomic Testing Program.

If you have questions, please contact your Network Specialist or Ancillary Contracting Specialist.

eviCore healthcare is an independent company that supports Horizon BCBSNJ in the provision of Medical Necessity Review (PA/MND) of certain molecular and genomic diagnostic testing services that are rendered in a physician’s office or clinical laboratory setting.

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

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

Published on: December 30, 2020, 11:04 a.m. ET
Last updated on: April 23, 2021, 02:05 a.m. ET