Molecular and Genetic Testing Billing Requirements

RML - Molecular Pre-Authorization Requisition

Providing the best possible care to you and your patients is always the number one priority with Regional Medical Laboratory. Many insurance companies are now requiring pre-authorization for genetic and molecular testing. Payers will only cover testing when used for certain diagnostic conditions. The payer may not cover the testing if it is done as a screening. RML is encouraging all our clients to check with the patient’s insurance before ordering genetic and molecular tests, to determine if pre-authorization is needed. If indicated, please obtain the pre-authorization prior to ordering and specimen collection. RML is unable to obtain the pre-authorization since we do not have access to the payer required clinical information. At this time, the request must come from the ordering physician to include the medical reason for the testing. Most payers will require CPT and ICD-10 codes for the authorization. RML will provide the appropriate CPT codes, the National Coverage Determination (NCD) and Local Coverage Determination (LCD) guidelines and payer policies listing the approved ICD10 diagnosis codes. If a pre-authorization is not obtained prior to specimen collection, testing may be delayed and the charges may become the responsibility of the patient. The Hyperlink below will provide a printer friendly alert values pages. Once open click the Printer Icon on the left side in the toolbar just above the form.

Molecular Pre-Authorization Requisition Forms

UnitedHealthcare Notification/Prior Authorization

Regional Medical Laboratory (RML) and Pathology Laboratory Associates (PLA) appreciate your business and value being a partner with you in managing the health of your patients. Consistent with the relationship, we would like to make you aware of some imminent changes that UnitedHealthcare is implementing. UnitedHealthcare will require notification/prior authorization for all molecular and genetic lab testing for patients in some plans. This new requirement from UnitedHealthcare will impact a broad range of molecular and genetic tests, including many standard of care tests.

UnitedHealthcare Notification/Prior Authorization

Genetic testing involves molecular analysis of human DNA, RNA, genes, and chromosomes to detect whether or not a person has an inherited trait or disorder, an acquired genetic alteration, a spontaneous genetic mutation, or is a carrier of a gene that could lead to a particular disorder or disease.

CommunityCare reimburses medically necessary genetic testing, genetic counseling, and human leukocyte antigen testing when it meets established coverage criteria and is performed by an approved provider. View the document below for more information.

Genetic Testing Payment Policy