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September 3, 2021 at 3:53 PM CT

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 from June 1, 2021 through October 1, 2021. Claims for these tests that have already been submitted will be reprocessed automatically. Please do not resubmit these claims.

Genetic and molecular testing prior authorization/advance notification (PAAN)

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 from June 1, 2021 through December 31, 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 prior authorization/advance notification (PAAN) process for genetic and molecular tests provides access and supports a positive experience for members and care providers.

The prior authorization/advance notification requirement for certain genetic and molecular tests applies to (see specific plan details below):

  • UnitedHealthcare® Exchange plans
  • Certain UnitedHealthcare commercial benefit plans, when UnitedHealthcare is the primary payer
  • Oxford Health Insurance plans
  • UnitedHealthcare Community Plans in select states

Ordering care providers can complete the prior authorization/advance notification process online or over the phone. Laboratories must register their tests to participate as part of the genetic and molecular testing prior authorization/advance notification process.

Tests requiring prior authorization/advance notification

For the current list of genetic and molecular tests that require prior authorization/advance notification, please go to UHCprovider.com/paan > Advance Notification and Plan Requirement Resources

Please refer to the Updated Notice of Changes to Plan Requirements for 2021 and review the product-specific prior authorization/advance notification requirements.

Commercial benefit plans: Prior authorization/advance notification 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. and UnitedHealthcare Insurance Company of the River Valley since July 1, 2019; for Oxford Health Insurance, Inc. since April 1, 2020; for All Savers Insurance Company and All Savers Life Insurance Company of California since Sept. 1, 2020; for UnitedHealthcare Exchange plans since Jan. 1, 2021;  and for Neighborhood Health Partnership, Inc. since June 1, 2021.

Community Plans: Prior authorization/advance notification for genetic and molecular testing performed in an outpatient setting is required for UnitedHealthcare Community Plan members in these states:

  • Beginning Feb. 1, 2019: Maryland, Michigan, Missouri, New York, Tennessee, Texas
  • Beginning March 1, 2019: Florida
  • Beginning April 1, 2019: New Jersey, Rhode Island
  • Beginning Feb. 1, 2020: Pennsylvania
  • Beginning May 1, 2020: Virginia
  • Beginning July 1, 2020: California, Hawaii, Wisconsin
  • Beginning Sept. 1, 2020: Washington
  • Beginning Nov. 1, 2020: Ohio
  • Beginning Dec. 1, 2020: Kansas
  • Beginning Jan. 1, 2021: Kentucky
  • Beginning July 1, 2021: North Carolina
  • Beginning Oct. 1, 2021: Mississippi

Tests not requiring prior authorization/advance notification

The genetic and molecular testing prior authorization/advance notification requirement does not apply to members in the following types of UnitedHealthcare and affiliate health plans:

  • UnitedHealthcare Medicare and Medicare Advantage plans, including dual special needs plans (DSNP)
  • These specific commercial plans:
    • Golden Rule Insurance Company
    • MAMSI Life and Health Insurance Company
    • MD-Individual Practice Association, Inc.
    • Optimum Choice, Inc.
    • PacifiCare Life and Health Insurance Company
    • Sierra Health and Life Insurance Company, Inc.
    • UnitedHealthcare West
    • UnitedHealthOne

But even though they’re not included in the standard prior authorization/advance notification process, the listed plans may still require prior authorization for certain genetic and molecular tests. You can find plan-specific prior authorization requirements in our medical policies and prior authorization lists.

Need Help?

If you have questions about the prior authorization/advance notification process, about using the online tools, or want to complete the prior authorization/advance notification process over the phone, call us at 877-303-7736. Representatives are available Monday–Friday, 7 a.m.–7 p.m. CT.