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Molecular and Genomic Testing Program Update for October 2019

Effective October 1, 2019, 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 to participate in the Molecular and Genomic Testing Program.

Beginning with services to be provided on and after October 1, 2019, eviCore will conduct pre-service Medical Necessity Determination (MND) reviews of the following additional diagnostic testing services [CPT® Proprietary Laboratory Analyses (PLA) codes which were recently added by the American Medical Association] when rendered in a physician’s office or clinical laboratory¹:

  •  0111U
  •  0113U
  •  0114U
  •  0118U
  •  0120U
  •  0129U
  •  0130U
  •  0131U
  •  0132U
  •  0133U
  •  0134U
  •  0135U
  •  0136U
  •  0137U
  •  0138U

Additionally, beginning with services to be provided on and after October 1, 2019, eviCore will no longer conduct pre-service MND reviews of deleted CPT code 0104U as part of our Molecular and Genomic Testing Program.

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

Further information about this specialty utilization management program is available on 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 Room, 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 by visiting www.evicore.com/healthplan/Horizon_Lab.

 

Published on: August 26, 2019, 09:11 a.m. ET
Last updated on: August 26, 2019, 03:53 a.m. ET