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Medical Necessity Determination (MND) Review of Molecular and Genomic Diagnostic Testing Services Frequently Asked Questions

Which Horizon products are included in the Molecular and Genomic Diagnostic Testing Program?

This program applies only to members enrolled in fully insured and Level Funded Horizon products, as well as Administrative Services Only (ASO) accounts that have elected to participate in the Molecular and Genomic Testing Program. This includes:

  • Horizon Direct Access
  • Horizon EPO, Indemnity/Traditional
  • Horizon HMO
  • Horizon POS
  • Horizon PPO
  • OMNIASM Health Plans

This program does not apply to the Federal Employee Program® (FEP®), the State Health Benefits Program (SHBP), the School Employees’ Health Benefits Program (SEHBP), Medicare Advantage (including Braven℠ Health), Medicare Supplementary, Medicaid or Fully Integrated Dual Eligible Special Needs (FIDE-SNP) plans.

What types of laboratory services are considered molecular and genomic testing?

Molecular and genomic testing laboratory services include the following laboratory study areas:

  • Hereditary cancer screening
  • Carrier screening tests
  • Tumor marker/molecular profiling
  • Hereditary cardiac disorders
  • Cardiovascular disease and thrombosis risk variant testing
  • Pharmacogenomic testing
  • Neurologic disorders
  • Mitochondrial disease testing
  • Intellectual disability/developmental disorders

Find a list of the CPT/HCPCS codes that require MND under this program.

What is the MND process for molecular and genomic diagnostic testing services?

For codes on eviCore’s list of CPT/HCPCS codes subject to pre-service MND review, providers should contact eviCore to obtain an MND prior to rendering services. This will help ensure that the services will be covered.

If a pre-service MND is not obtained, claims for molecular and genomic diagnostic testing services will be subject to post-service MND review.

There are three possible outcomes of an MND review:

1. Approved: the complete request meets the criteria for medical necessity.

2. Denied: the complete request does not meet clinical criteria.

3. Partial approval may be given if only part of the request is approved and the remainder is denied.

How do I initiate an MND?

A representative of the ordering physician’s staff can request a pre-service MND review.

Participating providers can initiate an MND by:

  • Visiting eviCore’s secure website.
  • Calling eviCore at 1-844-224-0493, weekdays, between 7 a.m. to 7 p.m., Eastern Time (ET). Multiple requests can be handled with one call.
  • Urgent requests must be made by phone and identified as urgent by calling 1-844-224-0493. Representatives are available after hours and on weekends.

Nonparticipating providers can initiate an MND by:

  • Calling 1-844-224-0493, weekdays, 7 a.m. to 7 p.m., ET.

If the rendering provider, who is not the ordering provider, calls eviCore to initiate an MND, eviCore will contact the ordering provider to obtain the necessary information for the review.

Can I initiate an MND via fax?

No. Requests should be made online or by phone.

What places of service are included in the Molecular and Genomic Testing Program?

Eligible places of service are:

  • Physicians’ offices
  • Clinical laboratories

Services rendered in the Emergency Room (ER), hospital outpatient or inpatient settings and Ambulatory Surgery Centers (ASCs) are excluded from the Molecular and Genomic Testing Program.

Are all providers – those who participate in Horizon’s network and those who don’t – included in the Molecular and Genomic Testing Program?

Yes. Participating and nonparticipating New Jersey and out-of-state providers are expected to comply with the MND requirements of the Molecular and Genomic Testing Program.

eviCore will not conduct pre- and post-service MND reviews for services to be provided to members enrolled in BlueCard® (ITS Host) or National Account (Par Other) coverage through another Blue Cross Blue Shield Plan. eviCore will only review these claims for frequency of testing, lifetime maximums or maximums per date of service. The review is not related to medical necessity.

What information is necessary to obtain an MND?

Information required by eviCore to make an MND on a particular molecular and genomic diagnostic testing service include:

Patient Demographic Information

  • Name
  • Date of birth
  • Health plan
  • Member ID number

Ordering Physician Information

  • Name
  • NPI number
  • Phone number
  • Fax number

Test Information

  • Specimen collection date
  • Requested CPT® code(s) and unit(s)
  • Requested test name(s)
  • Name of lab performing the test (include even if test will be billed to your institution)
  • Reason for the requested test (include how the test results will affect medical management)

Patient Medical/Family Histories

  • Patient’s relevant signs/symptoms
  • For female patients: Is the patient pregnant? If yes, how many babies?
  • Patient’s previous testing and test dates (include genetic tests and tests relevant to current request)
  • Patient’s ethnicity
  • Is the patient reported to have Ashkenazi Jewish ancestry?
  • Patient’s relevant family history (include relationship to patient, whether relative is maternal or paternal and age of onset of their condition)
  • Are there any known genetic disorders or mutations in the patient’s family? If yes, provide details.

Do I need a username and password to access eviCore’s application to request MND?

Yes. The online application is available to participating providers only. Refer to the Molecular and Genomic Testing Quick Reference Guide (QRG) for instructions on how to obtain a username and password.

What is the timeframe for eviCore to render an MND?

eviCore generally reviews requests and gives case determinations in three business days or less, dependent upon receiving all necessary clinical information.

If an MND is requested for an urgent condition, eviCore will give a determination as soon as possible, typically within 24 hours of receiving all necessary information. Providers should state that this pre-service MND request is for medically urgent care and requires expedited review.

How do I confirm that an approved MND for a patient has been issued?

There are two ways to confirm that an approved MND has been issued:

  • Rendering and ordering providers will receive a determination letter.
  • Rendering and ordering providers can view the MND determination via eviCore’s website application, or call eviCore toll-free at 1-844-224-0493 and select the Customer Service option.

How am I notified of eviCore’s MND?

A pre-service MND number will be faxed to the ordering physician and rendering laboratory upon approval. eviCore will approve a specific test and the CPT code(s) for molecular and genomic testing.

Please contact eviCore with any changes before the service is rendered.

It is the responsibility of the rendering laboratory to confirm that the pre-service MND process for molecular and genomic testing is complete. You can verify online or call 1-844-224-0493.

What is the difference between a case number and an MND number?

The case number is assigned at the start of a request. An MND number is not assigned until a final determination is made.

Is there a way to verify if an MND number has been assigned to a request?

Yes. Physicians, other health care providers and rendering laboratories can sign in to eviCore to view authorization status.

  • Select the member’s health plan and enter the provider ID number, Tax Identification Number (TIN) and office or provider name.
  • Enter the patient’s Horizon member ID number and date of birth and click Search.

Does a molecular and genomic diagnostic testing MND expire?

Yes. An approved MND is valid for 60 days. After that, because medical circumstances can change, a new MND request is required.

Are clinical trials part of this program?

No. Clinical trials are not part of this program. Please call Horizon’s Complex Case Management department at 1-888-621-5894, option 2 then follow prompts to the correct health plan, for laboratory testing within clinical trials.

How often is the Molecular and Genomic Testing Program CPT/HCPCS code list updated?

The Molecular and Genomic Testing Program CPT/HCPCS code list is reviewed annually or more frequently if necessary.

Why does eviCore’s website use the word “authorization” when this is an MND program?

Although eviCore’s website references “authorizations” in several instances, the Molecular and Genomic Testing Program is an MND program.

Claims

Where should I send claims once I provide services?

There are no changes to where you should send claims.

How does eviCore handle claims?

Claims for molecular and genomic testing services that have an approved MND review, if applicable, will be processed and reimbursed according to eviCore’s frequency rules and service maximums.

How does eviCore handle BlueCard claims?

eviCore will only apply claim editing logic that is not related to medical necessity to BlueCard (ITS Host) or National Account (Par Other) claims. Such claim editing logic focuses on frequency of testing, lifetime maximums or maximums per date of service.

What is required to expedite claims processing?

To expedite claims processing, the following information is needed:

  • Approved MND number, if applicable
  • Appropriate HCPCS code for the procedure
  • Itemized date(s) of service

Appeals

How do I dispute an eviCore MND adverse determination?

Information on how to appeal an adverse determination will be provided in the letter issued by eviCore at the completion of the MND review. Please note: eviCore will not provide pre- and post-service UM and UM Appeals review for BlueCard (ITS Host) or National Account (Par Other) services.

Generally, providers may dispute an adverse determination based on medical necessity as follows:

By phone: call eviCore at 1-866-241-6603

By mail:

eviCore healthcare
Attn: Appeals Coordinator
400 Buckwalter Place Boulevard
Bluffton, SC 29910

 

By fax: 1-866-699-8128

Who can I contact for information about a UM First Level Appeal I submitted?

For an appeal involving an MND, call eviCore at 1-866-241-6603.

How do I dispute an adverse determination that is not related to an MND?

A provider may dispute an adverse claim determination that is not related to an MND (a determination not based on medical judgment) by contacting Horizon:

  • Physician Services: 1-800-624-1110
  • Facility Centralized Service Center: 1-888-666-2535

Members can call Member Services at 1-800-355-BLUE (2583) or the phone number on the back of their member ID card.