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Genetic and Molecular Lab Testing Notification/Prior Authorization

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.

Notification is required for certain genetic and molecular lab tests for certain UnitedHealthcare Commercial benefit plans. 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.

Frequently Asked Questions.

 

Notification/Prior Authorization Required

The notification/prior authorization requirement applies to UnitedHealthcare commercial benefit plans when UnitedHealthcare is the primary payer.

Starting April 1, 2018, a completed notification/prior authorization process for genetic and molecular tests is required for members in the UnitedHealthcare of the Mid- Atlantic, Inc. benefit plan.

Notification / Prior Authorization Not Required

The Genetic and Molecular Lab Testing Notification/Prior Authorization requirement does not apply to members in these types of UnitedHealthcare and affiliate health plans:

  • All UnitedHealthcare Medicare and Medicare Advantage plans
  • UnitedHealthcare Community Plans
  • Commercial Plans
    • All Savers Insurance Company
    • All Savers Life Insurance Company of California
    • Golden Rule Insurance Company
    • MAMSI Life and Health Insurance Company
    • MD-Individual Practice Association, Inc.
    • Neighborhood Health Partnership, Inc.
    • Optimum Choice, Inc.
    • Oxford Health Insurance, Inc.
    • PacifiCare Life and Health Insurance Company
    • Sierra Health and Life Insurance Company, Inc.
    • UnitedHealthcare of the River Valley, Inc.
    • UnitedHealthcare West
    • UnitedHealthOne

The notification/prior authorization requirement also doesn’t apply to:

When you submit or review a notification/prior authorization request in the Genetic and Molecular Test app on Link, you may see a “case status” listed. Here’s what the status means:

  • Approved. The case has been completed and a notification/authorization has been provided for the selected treatment.
  • Incomplete. The case has been started, but not finished. All cases that are incomplete will give the ordering care provider the option to “Resume” or “Cancel” the request.
    • “Resume” returns you to the last completed question in the request. You can get back into your incomplete request for 14 days, after which the request will expire. If you still need a notification/prior authorization, you’ll have to submit a new request.
    • "Cancel” withdraws the request.
  • Pending Clinical Review. The case has been submitted and is under clinical review. We’ll contact you if more information or a physician-to-physician discussion is required.
  • Pending Registration. Your request was received and BeaconLBS, our vendor managing this process, is contacting the requested laboratory for additional information.
  • Withdrawn. You canceled the request. If you still need a notification/prior authorization, you’ll have to submit a new request.
  • Expired. The case is no longer active. This is a system status; an incomplete request was not completed within 14 days.
  • Non-certified. The medical review determined that the requested treatment was unproven.

The following genetic and molecular tests are included in the notification/prior authorization requirement:

  • Tier 1 Molecular Pathology Procedures
  • Tier 2 Molecular Pathology Procedures
  • Genomic Sequencing Procedures
  • Multianalyte Assays with Algorithmic Analyses that include Molecular Pathology Testing
  • These CPT® codes:
    • 0001U
    • 0018U     0019U 
    • 0022U     0023U 
    • 0026U     0034U 
    • 0036U     0037U 
    • 0040U
    • 0045U     0050U 
    • 0055U     0057U 
    • 0060U
    • 0004M
    • 0006M     0007M 
    • 0009M
    • 0011M     0013M 
    • 81105     81111 
    • 81120     81121 
    • 81161     81420 
    • 81425     81479 
    • 81507
    • 81519     81521  
    • 81545
    • 81595     81599 
    • S3870

We’ll use the following medical policies to review requests for genetic and molecular testing:

  • Carrier Testing for Genetic Diseases
  • Chromosome Microarray Testing
  • Fetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood
  • Genetic Testing for Hereditary Cancer 
  • Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions 
  • Pharmacogenetic Testing 
  • Whole Exome and Whole Genome Sequencing

To view the latest policy information, please visit the Policy section at UHCprovider.com/Policies

Need Help?

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.