Molecular and Genomic Testing Program

Horizon BCBSNJ collaborates with eviCore healthcare (eviCore) to conduct pre- and post-service Medical Necessity Determination (MND) reviews of certain molecular and genomic diagnostic testing services that are rendered in a physician’s office or clinical laboratory setting. This applies to Horizon BCBSNJ members enrolled in fully-insured products and Administrative Services Only (ASO) accounts that have elected to participate in the Molecular and Genomic Testing Program.

A listing of the tests that are subject to MND review under this program can be viewed here.

Claims for molecular and genomic diagnostic laboratory testing services provided on and after August 1, 2017, for which no pre-service MND is obtained, will be delayed or denied while information for eviCore to conduct post-service MND is requested and reviewed. Claims for molecular and genomic diagnostic laboratory testing services deemed not medically necessary through post-service review will not be considered for reimbursement.

Policies

Horizon BCBSNJ has adopted the eviCore guidelines for determining the medical necessity of molecular and genomic diagnostic laboratory testing services for use with members who are enrolled in plans that participate in the Molecular and Genomic Testing Program administered by eviCore.

Visit www.evicore.com/healthplan/Horizon_Lab to access the molecular and genomic diagnostic laboratory testing guidelines that apply to members enrolled in plans that have elected to participate in Molecular and Genomic Testing Program administered by eviCore.

The eviCore guidelines were developed using recognized evidence-based guidelines and incorporate criteria derived from published materials that are supported by nationally recognized agencies.

Please note that the Molecular and Genomic Testing guidelines maintained on eviCore’s website pertain only to members who are enrolled in Horizon BCBSNJ plans that participate in the Molecular and Genomic Testing Program administered by eviCore.

As part of this program, all claims for molecular and genomic testing services within the scope of this program rendered August 1, 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. Such claim editing logic focuses on frequency of testing, lifetime maximums or maximums per date of service. Visit www.evicore.com/healthplan/Horizon_Lab to review these guidelines.

 

Resources

Molecular and Genomic Testing Program Quick Reference Guide

Molecular and Genomic Testing Program Q&A

Molecular and Genomic Testing Procedure Code Listing

Horizon BCBSNJ announcement of the Molecular and Genomic Testing Program