![]() If a patient is not found in the Carelon database, we recommend contacting the health plan to verify the necessary preauthorization requirements for that patient. If the patient is not found in the Carelon database, does this mean that a request does not need to be entered for the member? The portal will allow the user to proceed with the case if the member is included in the program. How do I know if my patient requires preauthorization for genetic testing?Ī provider can look up their patient on the portal. Contacting Carelon prior to the performance of a test will provide you the information of whether or not the test is medically necessary and therefore a covered benefit for the member. If you contact the health plan, you will be directed to use the provider portal or call the Carelon contact center. What happens if I do not contact Carelon for preauthorization of genetic testing? Currently, there is very little evidence for the results of some of these tests to have meaningful impact on determining what medications to prescribe, the proper dosages or health outcomes. Examples include some tests that fall under the category known as pharmacogenomics testing, where certain genetic changes may be associated with different metabolism of certain drug classes. Coverage for these tests are generally not recommended. ![]() Why are some genetic tests not covered by my insurance company?Ĭertain genetic tests have no proven impact on patients’ overall health and have not shown any clinical benefit from either a diagnosis or treatment standpoint. Many times, the genetic information allows for screening that leads to early detection, reducing the medical and financial impact, both medically and financially for both the patient and the health system. For those tests that meet the medical management and outcomes benchmark, there can be tremendous reduction in morbidity and mortality. Why are only some genetic tests covered by my insurance company?Ĭoverage is generally approved for genetic tests that provide information that can help manage the care of patients and have a positive impact on their overall health and well-being or help avoid potentially harmful treatments. The test must be at least as beneficial as other alternatives if they exist and the results obtainable outside of investigational settings. How is a genetic test determined to be medically necessary?Īs a general rule, genetic tests must be based on evidence from well-designed, well-conducted clinical studies that demonstrate that the test leads to information that impacts health and well-being of patients. Tests that may be covered if clinical criteria are met include but are not limited to: hereditary cancer predisposition testing, such as, BRCA testing for breast and ovarian cancer syndromes tumor maker analysis for cancer tumor testing to help determine treatment regimens and prenatal testing, such as cell-free fetal DNA testing for evaluation of chromosome and other genetic conditions. Many genetic tests have specific clinical criteria that must be met prior to approval of the testing. How is coverage for genetic testing determined and why?Ĭoverage for genetic testing is dependent on a determination of what is medically necessary, as defined in the clinical criteria set forth in health plan medical policy or clinical guidelines. Please refer to your patient’s health plan for more information regarding which tests fall under their specific genetic testing program. Which genetic tests require a preauthorization can vary by plan. Will all genetic tests require preauthorization under the genetic testing program? Participating in the program is most easily managed using the provider portal, available 24/7, or by calling Carelon directly. The genetic testing program will be administered by Carelon on behalf of your patient’s health plan. How will the genetic testing program be administered? Synchronization with health plan medical policy and clinical guidelines.Assurance that your practice is providing evidence-based care.When requested, Carelon can provide access to a database of genetic counseling providers.24/7 online access to the Carelon Medical Benefits Management provider portal, a proven technology platform to process reviews in real time.Practices participating in the program can gain efficiency through: How can this program benefit my practice? ![]() In collaboration with you and your patient’s health plan, the genetic testing program helps ensure care that’s appropriate and affordable. The genetic testing program assists your practice in delivering evidence-based and cost-effective care for your patients who would benefit from genetic testing. ![]()
0 Comments
Leave a Reply. |
Details
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |