Resources

Precertification for genetic testing was implemented in coordination with Carelon Medical Benefits Management to provide you with the tools and resources you need to determine the most appropriate, cost-effective genetic testing for each patient.

Precertification for genetic testing is required for most Blue Cross members (including Blue Advantage^® members).

Precertification Process

Order Request – Check eligibility and benefits through ProviderAccess to determine if precertification is required for a patient. If precertification is required, you can begin the process through Eligibility and Benefits. A link to “Initiate Precertification” can be found on the “Additional Coverage” tab.

Review – Your request will be submitted to Carelon and evaluated as to:

• Alignment with clinical guidelines and medical policies
• Satisfaction of genetic counseling requirements when required by applicable clinical criteria
• Use of an in-network laboratory

Determination – When your request aligns with applicable clinical criteria and medical policies, you will receive an immediate approval. If an adverse determination is going to be made, a peer-to-peer discussion with a physician reviewer is always offered first.

Precertification for genetic testing is required through this program and supported by the following:

Actionable Information

When your practice submits an order request for genetic testing, it will be compared against evidence-based clinical guidelines and medical policies. Requests that meet the applicable clinical criteria will be automatically approved.

Requests that do not meet the applicable clinical criteria will be sent for further review by physician reviewers. More appropriate testing may be recommended for your patient. Sometimes, testing can be approved when additional clinical information is provided. 

Clinical Criteria

The review takes into consideration Blue Cross medical policies as well as clinical guidelines developed by a Carelon Medical Benefits Management team that includes board-certified genetic counselors and medical geneticists. All of their clinical criteria is based on a review of evidence, including peer-reviewed resources, medical society guidelines and practice bulletins. Information is continuously updated to keep pace with this rapidly evolving field.

While the program is designed to identify the most appropriate test for an individual patient, you may have specific reasons to order another test. That’s why this program has built-in flexibility to approve such requests when applicable clinical criteria are met as determined by genetic counseling providers and peer-to-peer reviews.

Resources

• Carelon's genetic testing webpage:
  • Worksheets – Helpful guides to assist you in the precertification process
  • Clinical Appropriateness Guidelines
  • FAQs
• Blue Advantage Genetic Testing policies
• Genetic Testing Precertification tutorial video
• Blue Advantage list of CPT/HCPCS codes that require precertification
• CPT/HCPCS codes that require precertification
• Genetic Testing policies

Carelon is an independent company that provides clinical solutions that drive appropriate, safe and affordable care.