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Molecular and Genomic Testing to be subject to Medical Necessity Determination (MND) Review

Beginning July 3, 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

A listing of the tests that are subject to MND review under this program can be viewed by accessing the link below:

Molecular and Genomic Testing Procedure Code Listing

This program applies only to laboratory services to be provided to 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 administered by eviCore. Note: Members enrolled in Medicare Advantage (MA) plans are excluded from this program.

Pre-service MND reviews
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

Physicians are strongly encouraged to obtain a pre-service MND from eviCore prior to ordering molecular and genomic diagnostic testing for their Horizon BCBSNJ patients to ensure that services will be considered medically necessary. Rendering clinical laboratory providers are encouraged to validate that an approved pre-service MND has been obtained from eviCore by confirming it with the ordering physician or by contacting eviCore as described below.

Claims for molecular and genomic testing services provided July 3, 2017 and after, for which no pre-service MND was obtained, will be delayed or denied while information for eviCore to conduct post-service MND is requested and reviewed. Claims for molecular and genomic testing deemed not medically necessary through post-service review will not be considered for reimbursement.

How to obtain pre-service MND for molecular and genomic testing
To obtain pre-service MND from eviCore, referring physicians should:

  • Submit a request online through www.eviCore.com; or
  • Call 1-844-224-0493, between 7 a.m. and 7 p.m., Eastern Time (ET).

You must provide eviCore with:

  • Specimen collection date (if applicable)
  • Type or Test Name (if known)
  • CPT® code(s) and units
  • ICD code(s) relevant to requested test
  • Test indication (personal history of condition being tested, age at initial diagnosis, relevant signs and symptoms, if applicable)
  • Relevant past test results
  • Member’s or patient’s ethnicity
  • Relevant family history, if applicable (maternal or paternal relationship, medical history, including ages at diagnosis, genetic testing)
  • The specific mutation, if there is a known familial mutation
  • How the test results will be used in the member’s or patient’s care
  • Any pertinent clinical documentation that will support the test request
  • Patient’s name, date of birth, address
  • Member ID number
  • Referring physician’s National Provider Identifier (NPI), phone and fax
  • Rendering laboratory’s NPI, phone and fax

eviCore Guidelines
Visit www.evicore.com/healthplan/Horizon_Lab to review the guidelines that eviCore will use to conduct MND reviews of molecular and genomic diagnostic testing for Horizon BCBSNJ members enrolled in plans that participate in the Molecular and Genomic Testing Program.

eviCore’s guidelines pertain only to services to be provided to members enrolled in plans that participate in the Molecular and Genomic Testing Program. Beginning July 3, 2017 Horizon BCBSNJ will display medical policies within our online Medical Policy Manual, the guidelines of which will pertain only to services provided to members enrolled in plans that do not participate in the Molecular and Genomic Testing Program.

How to validate pre-service MND for molecular and genomic testing was performed
Referring or rendering providers, including physicians and clinical laboratory providers, are able to validate that a pre-service MND was requested and approved for a particular patient by checking pre-service MND status on www.eviCore.com or by calling eviCore’s Customer Service department at 1-844-224-0493, between 7 a.m. and 7 p.m., ET.

As part of this program, claims for molecular and genomic testing services rendered July 3, 2017 and after will be processed and reimbursed in a manner that is consistent with eviCore’s guidelines in regard to molecular and genomic testing service frequency rules and service maximums. Visit www.evicore.com/healthplan/Horizon_Lab to review these guidelines.

If you have questions about this program, 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.

Published on: March 31, 2017, 01:48 a.m. ET
Last updated on: June 28, 2017, 18:00 p.m. ET