Update – Genetic and Molecular Prior Authorizations
We are waiving administrative penalties if you are unable to complete the prior authorization or notification requirement for any genetic or molecular test with a date of service of June or July 2021. Claims for these tests that have already been submitted will be reprocessed automatically. Please do not resubmit these claims.
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 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 over the phone for UnitedHealthcare Exchange plans.
Ordering care providers will complete the notification/prior authorization process online or over the phone for other plans with the notification/prior authorization requirement. 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; All Savers Life Insurance Company of California since Sept. 1, 2020; UnitedHealthcare Exchange plans effective Jan. 1, 2021; and Neighborhood Health Partnership, Inc. effective June 1, 2021.
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.
For the most current list of genetic and molecular tests that require notification/prior authorization, please go to UHCprovider.com/paan > Advance Notification and Plan Requirement Resources.
Please refer to the Updated Notice of Changes to Plan Requirements for 2020 and review the product-specific notification/prior authorization requirements and code section.
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:
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 877-303-7736. Representatives are available Monday - Friday from 7 a.m. to 7 p.m.