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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

December 2017

Webinar for Genetic Testing Authorization for Medicare Members

Harvard Pilgrim and AIM Specialty Health are hosting an additional webinar for providers who want to learn more about the genetic/genomic and molecular testing program for our Medicare Advantage members.

The webinar will be offered on Wednesday, Dec. 20th at noon. Registration is not required. For information and to connect to the meeting, please visit the webinar website.

Additional webinars will be offered in the first quarter of 2018, at which time we anticipate expanding the genetic testing authorization program to include our commercial members.

Overview of the genetic testing program

As we announced in the October issue of Network Matters, for dates of service beginning Jan. 1, 2018, Harvard Pilgrim is requiring prior authorization through AIM Specialty Health for genetic/genomic and molecular testing for our Medicare Advantage members, including:

  • Genetic testing for hereditary cardiac disease
  • Genetic testing for hereditary cancer susceptibility
  • Genetic testing for single-gene and multifactorial conditions
  • Pharmacogenetic and thrombophilia genetic testing
  • Reproductive carrier screening and prenatal diagnosis
  • Somatic tumor testing
  • Whole genome sequencing

Under this program, the ordering clinician is responsible for obtaining prior authorization through AIM Specialty Health. Providers may begin making prior authorization requests for genetic/genomic and molecular testing beginning Dec. 18, 2017.

Any genetic/genomic and molecular tests performed on or beyond Jan. 1, 2018 will not be reimbursed if a prior authorization was not obtained. To ensure that they are eligible for reimbursement, providers rendering these services should verify that the necessary prior authorization has been obtained prior to performing the test. Ordering providers should request prior authorization in one of the following ways:

More information

Please refer to our Stride (HMO) Medicare Advantage Molecular Diagnostic Management Medical Review Criteria and Molecular Diagnostic Management Authorization Policy for Stride for complete information.

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Network Matters Archives

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Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Senior Vice President, Network Strategy

Annmarie Dadoly,

Joseph O'Riordan,

Kristin Edmonston,
Production Coordinator