Update: Molecular and Genomic Testing Program to be implemented

We previously announced that beginning July 3, 2017, eviCore healthcare (eviCore) will conduct pre-service Medical Necessity Determination (MND) reviews of certain molecular and genomic diagnostic testing services as part of our Molecular and Genomic Testing Program. Please note the new implementation date is August 1, 2017.

MND will be conducted for certain molecular and genomic diagnosing testing services rendered in a physician’s office or a clinical laboratory.¹

This program applies to laboratory services that are 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. Members enrolled in Medicare Advantage (MA) plans are excluded from this program.

As part of this program, claims for all molecular and genomic testing services within the scope of this new program rendered on and after August 1, 2017 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.

For more information, including a listing of the tests that are subject to MND review under this program, details about pre-service MND reviews, eviCore guidelines, and more, please visit our new Molecular and Genomic Testing Program web page.

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).