Although UnitedHealthcare already requires prior authorization for genetic and molecular testing, the health insurer will roll out an online program nationally this fall for tests performed in an outpatient setting. The offering, according to the company, should help streamline the process and give insight into costs for multiple tests.

Providers requesting lab testing will need to complete the prior-authorization process themselves, while participating labs “will be responsible for determining if an authorization has been received,” according to a network bulletin. Services performed that have not been authorized “will be denied and the member can’t be balance billed,” says the insurer. “If an authorization has not been granted, the participating laboratory staff should contact the ordering care provider to request a prior authorization.”

The Genetic Molecular Testing Prior Authorization Program will go into effect for UnitedHealthcare’s fully insured commercial members Oct. 1, says Lynne High, a spokesperson for the health plan. However, says the company, “Laboratory services ordered for members in Florida with a BeaconLBS logo on their identification card will not be required to participate in this requirement due to their participation in the UnitedHealthcare Laboratory Benefit Management Program.”

To support the program, “we will be working with a vendor to provide an online genetic and molecular prior authorization intake system based on the UnitedHealthcare Medical Policies,” High explains. She declines to identify the vendor with which United will work. In a recent network bulletin, the insurer explains, “The vendor will have an online prior authorization program available, and requests that meet our clinical criteria will be granted an authorization at the time of the request. UnitedHealthcare’s medical policies, based on peer-reviewed, published literature, will be used for coverage determination. Our medical policies are reviewed and updated at least annually.”

In the network bulletin, UnitedHealthcare says that “Laboratories that perform genetic or molecular testing will be asked to provide details on their genetic and molecular tests (i.e., test name, test ID number, codes used for billing, etc.) to our selected vendor starting in the second quarter of 2017. This information will be required for UnitedHealthcare to complete an authorization.”

Prior authorization notification will be required for the following:

  • Tier 1 Molecular Pathology Procedures

  • Tier 2 Molecular Pathology Procedures

  • Genomic Sequencing Procedures

  • Multianalyte Assays with Algorithmic Analyses that include Molecular Pathology Testing

  • CPT codes included in the prior authorization: 0001U, 0004M–0008M, 81161–81421, 81423–81479, 81507, 81519 and 81545–81599.

Training for the program and additional information will be available at around Sept. 1.

Program Will Help With Transparency

“Prior authorization is a key component to helping UnitedHealthcare members have access to quality, affordable health care,” maintains High. “The online program for genetic and molecular testing streamlines the prior-authorization process (vs. having to place phone calls or send faxes) and provides cost transparency for a number of tests performed in an outpatient setting, including BRCA1/2, Hereditary Cancer Panels and Pharmacogenetic Panels.”

“All utilization management activities will be managed by” UnitedHealthcare, she adds.