We’re committed to working with consumers and care providers to support improved population health outcomes, positive care experiences and affordable products. An increasingly important part of this commitment includes coordinating coverage guidelines and policies for new and emerging technologies, including genetic testing.
By working with you, we can provide access to this emerging field and promising new treatments for patients while balancing patient safety and clinical evidence. Our new online notification/prior authorization process for genetic and molecular lab tests will help provide access while supporting a better care experience for members and care providers.
The notification/prior authorization requirement for certain genetic and molecular tests applies to:
Ordering care providers will complete the notification/prior authorization process online or over the phone. Labs must register their tests to participate as part of the Genetic and Molecular Lab Testing Notification/Prior Authorization process.
Notification/prior authorization for genetic and molecular tests has been required for certain UnitedHealthcare commercial benefit plans since Nov. 1, 2017; for UnitedHealthcare of the Mid-Atlantic, Inc. benefit plan members since April 1, 2018; for UnitedHealthcare Plan of the River Valley, Inc., UnitedHealthcare Insurance Company of the River Valley since July 1, 2019; for Oxford Health Insurance, Inc. since April 1, 2020; and All Savers Insurance Company, All Savers Life Insurance Company of California effective Sept. 1, 2020.
UnitedHealthcare requires that care providers complete the notification/prior authorization process for genetic and molecular testing performed in an outpatient setting for UnitedHealthcare Community Plan members in these states:
Beginning Oct. 1, 2020, for all commercial and UnitedHealthcare Community Plan plans included in the genetic and molecular testing program, we are suspending prior authorization and notification requirements for the following three genetic and molecular CPT codes performed in an outpatient setting:
These codes were part of the expansion of the online prior authorization and notification program for genetic and molecular testing that took effect on July 1, 2020. We’re suspending the codes indefinitely to ease the administrative burden for care providers during the COVID-19 national public health emergency. Please note that we will be reviewing claims for these codes to ensure they are being billed appropriately.
The Genetic and Molecular Lab Testing Notification/Prior Authorization requirement does not apply to members in the following types of UnitedHealthcare and affiliate health plans. Even though they’re not included in the Genetic and Molecular Lab Testing Notification/Prior Authorization requirement, the listed plans may still require prior authorization for genetic and molecular tests. You can find plan-specific prior authorization requirements in our medical policies and prior authorization lists.
All UnitedHealthcare Medicare and Medicare Advantage plans, including Dual Special Needs Plans (DSNP) and these specific commercial plans:
When you submit or review a notification/prior authorization request in the Genetic and Molecular Test tool in Link, you may see a “case status” listed. Here’s what the status means:
The following genetic and molecular tests are included in the notification/prior authorization requirement:
We’ll use the following medical policies to review requests for genetic and molecular testing:
To view the latest policy information, please visit the Policy section at UHCprovider.com/policies.
If you have questions about the notification/prior authorization process, about using the online tools, or want to complete the notification/prior authorization process over the phone call us at 800-377-8809. Representatives are available Monday - Friday from 7 a.m. to 7 p.m.
Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Health plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California, UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of the Mid-Atlantic, Inc., MAMSI Life and Health Insurance Company, UnitedHealthcare of New York, Inc., UnitedHealthcare Insurance Company of New York, UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Pennsylvania, Inc., UnitedHealthcare of Texas, Inc., UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Utah, Inc., UnitedHealthcare of Washington, Inc., Optimum Choice, Inc., Oxford Health Insurance, Inc., Oxford Health Plans (NJ), Inc., Oxford Health Plans (CT), Inc., All Savers Insurance Company, or other affiliates. Administrative services provided by OptumHealth Care Solutions, LLC, OptumRx, Oxford Health Plans LLC, United HealthCare Services, Inc., or other affiliates. Behavioral health products provided by U.S. Behavioral Health Plan, California (USBHPC), or its affiliates.