Frequently asked questions
What is the genetic testing program?
The genetic testing program assists your practice in delivering evidence-based and cost-effective care for your patients who would benefit from genetic testing. In collaboration with you and your patient’s health plan, the genetic testing program helps ensure care that’s appropriate and affordable.
How can this program benefit my practice?
Practices participating in the program can gain efficiency through:
- 24/7 online access to the Carelon Medical Benefits Management provider portal, a proven technology platform to process reviews in real time
- When requested, Carelon can provide access to a database of genetic counseling providers
- Assurance that your practice is providing evidence-based care
- Synchronization with health plan medical policy and clinical guidelines
How will the genetic testing program be administered?
The genetic testing program will be administered by Carelon on behalf of your patient’s health plan. Participating in the program is most easily managed using the provider portal, available 24/7, or by calling Carelon directly.
Will all genetic tests require preauthorization under the genetic testing program?
Which genetic tests require a preauthorization can vary by plan. Please refer to your patient’s health plan for more information regarding which tests fall under their specific genetic testing program.
How is coverage for genetic testing determined and why?
Coverage for genetic testing is dependent on a determination of what is medically necessary, as defined in the clinical criteria set forth in health plan medical policy or clinical guidelines. Many genetic tests have specific clinical criteria that must be met prior to approval of the testing. Tests that may be covered if clinical criteria are met include but are not limited to: hereditary cancer predisposition testing, such as, BRCA testing for breast and ovarian cancer syndromes; tumor maker analysis for cancer tumor testing to help determine treatment regimens; and prenatal testing, such as cell-free fetal DNA testing for evaluation of chromosome and other genetic conditions.
How is a genetic test determined to be medically necessary?
As a general rule, genetic tests must be based on evidence from well-designed, well-conducted clinical studies that demonstrate that the test leads to information that impacts health and well-being of patients. The test must be at least as beneficial as other alternatives if they exist and the results obtainable outside of investigational settings.
Why are only some genetic tests covered by my insurance company?
Coverage is generally approved for genetic tests that provide information that can help manage the care of patients and have a positive impact on their overall health and well-being or help avoid potentially harmful treatments. For those tests that meet the medical management and outcomes benchmark, there can be tremendous reduction in morbidity and mortality. Many times, the genetic information allows for screening that leads to early detection, reducing the medical and financial impact, both medically and financially for both the patient and the health system.
Why are some genetic tests not covered by my insurance company?
Certain genetic tests have no proven impact on patients’ overall health and have not shown any clinical benefit from either a diagnosis or treatment standpoint. Coverage for these tests are generally not recommended. Examples include some tests that fall under the category known as pharmacogenomics testing, where certain genetic changes may be associated with different metabolism of certain drug classes. Currently, there is very little evidence for the results of some of these tests to have meaningful impact on determining what medications to prescribe, the proper dosages or health outcomes.
What happens if I do not contact Carelon for preauthorization of genetic testing?
If you contact the health plan, you will be directed to use the provider portal or call the Carelon contact center. Contacting Carelon prior to the performance of a test will provide you the information of whether or not the test is medically necessary and therefore a covered benefit for the member.
How do I know if my patient requires preauthorization for genetic testing?
A provider can look up their patient on the portal. The portal will allow the user to proceed with the case if the member is included in the program.
If the patient is not found in the Carelon database, does this mean that a request does not need to be entered for the member?
If a patient is not found in the Carelon database, we recommend contacting the health plan to verify the necessary preauthorization requirements for that patient.
When the health plan is not the member’s primary insurance, does this program apply to the member?
No, the program only applies to members who have the health plan as primary.
Who can submit order requests?
Ordering providers or a member of their staff may submit order requests for genetic testing. The preferred method is via the provider portal.
How do I use the provider portal to submit my request?
A step-by-step tutorial on using the provider portal to submit your request can be accessed by going to www.providerportal.com.
What date of service should be included on the request for prior authorization?
Please complete the date of service field with the date that the laboratory likely will begin the testing process. Do NOT use the date the sample is collected unless the test is being performed by the laboratory on that same day. If the exact test date is unknown, please enter an estimated date that is one to three days after the sample is scheduled to arrive at the laboratory; doing so will facilitate approvals in the vast majority of situations.
What information is needed to submit a genetic testing order request?
Carelon has developed a number of genetic testing order request worksheets outlining what information is helpful in order to submit a request for genetic testing. These worksheets can be found here
Once a request has been submitted, how long will it take to receive a response from Carelon?
Requests that meet criteria receive a response instantly through the provider portal or on the phone with the Carelon contact center. Request that require further review may take up to 5 days, although this may vary by plan and state.
After a case is completed, is a letter sent to the provider as to whether the services was approved or denied?
Yes. Generally speaking, the ordering provider will receive written notification of the final decision. In addition, the ordered tests and approvals, including an order number, can be obtained immediately online through provider portal.
How long is an order number valid?
Once an order request has been submitted, the order summary will provide the valid timeframe of the authorization; although it is typically 90 days.
What should I do if I believe the denial I received is in error or I wish to request an exception for testing?
If you have received a denial and believe it to be in error or wish to request an exception, please follow the appeal process outlined in the letter you received with the denial.
Program designs vary by health plan. We encourage you to review the FAQs for each patient’s plan on the Resources page.