Molecular and Genomic Testing Program Update: November 2018

Based on Proprietary Laboratory Analyses (PLA) code changes recently announced by the American Medical Association (AMA), Horizon Blue Cross Blue Shield of New Jersey will implement the changes noted below to our Molecular and Genomic Testing Program, administered by eviCore healthcare (eviCore).

• Beginning with services to be provided on and after November 15, 2018, eviCore will conduct pre-service Medical Necessity Determination (MND) reviews of the following additional CPT® codes when rendered in a physician’s office or clinical laboratory.¹
  0067U
  0069U
  0070U
  0071U
  0072U
  0073U
  0074U
  0075U
  0076U
  0078U
  0079U
   
• Effective October 1, 2018, eviCore no longer conducts pre-service MND reviews of CPT code 0028U (the AMA removed this code October 1, 2018) as part of the Molecular and Genomic Testing Program.

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

Our Molecular and Genomic Testing Program applies to patients enrolled in Horizon BCBSNJ fully-insured commercial plans/products as well as to patients enrolled in administrative services only (ASO) plans that have elected the Molecular and Genomic Testing Program. For more information, visit the Molecular and Genomic Testing Program web page,

If you have questions, 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 at www.evicore.com/healthplan/Horizon_Lab.