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

January 2018

Genetic Testing Prior Authorization for Commercial Members


Harvard Pilgrim introduced a prior authorization requirement for genetic testing for Medicare Advantage members in January, and will be expanding the program to include commercial members. Effective March 1, 2018, Harvard Pilgrim is requiring prior authorization through AIM Specialty Health® (AIM) for commercial members enrolled in our HMO, PPO, POS and Access America products for genetic/genomic or molecular tests, including those associated with:

  • Hereditary cardiac disease
  • Hereditary cancer susceptibility
  • Single-gene and multifactorial conditions
  • Pharmacogenetics and thrombotic disorders
  • Reproductive carrier screening and prenatal diagnosis
  • Solid and hematologic tumors and malignancies
  • Whole exome/genome sequencing

Additionally, preauthorization through AIM is required for the CPT codes 89290 and 89291 associated with preimplantation genetic diagnosis.

AIM will review requests for genetic tests against current, evidence-based clinical appropriateness guidelines. AIM includes three levels of clinical governance in the development of clinical appropriateness guidelines: review of published literature by practicing physicians with expertise in their fields; consultation with independent subject matter experts; and review by an independent panel of multispecialty physicians.

Requesting prior authorization

The ordering clinician is responsible for obtaining prior authorization through AIM. Any genetic/genomic and molecular tests performed on or beyond March 1, 2018 will not be reimbursed if a prior authorization was not obtained. Therefore, to ensure payment of the claim, 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:

Providers may contact AIM with prior authorization requests for genetic/genomic and molecular testing beginning Feb. 20, 2018 for dates of service of March 1, 2018 and beyond. Please continue to contact Harvard Pilgrim to request authorization for any genetic testing services that we currently manage (including genetic testing for hereditary breast and/or ovarian cancer) if the date of service will be before March 1, 2018.

Genetic counseling

Patients must first receive genetic counseling before certain test requests can be authorized. When requesting authorization for a test requiring genetic counseling, the ordering provider must provide the name of the genetic counseling provider and the date of that service. If you are using the AIM portal to request authorization, the system will prompt you to include this information; if genetic counseling has not been completed, the portal will supply a list of genetic counseling resources for your consideration.

Provider education webinars

Harvard Pilgrim and AIM will be hosting provider education webinars for those who want to learn more about prior authorization for genetic/genomic and molecular testing. This one-hour session will provide useful information about the program and an opportunity to receive answers to any questions you may have. Provider education webinars will be offered on the following dates:

Registration is not required. For information and to connect to the meeting, please visit the webinar websites provided above.

Additional information

For further details, please refer to the following:

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PUBLICATION INFORMATION

Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Senior Vice President, Network Strategy

Annmarie Dadoly,
Editor

Joseph O'Riordan,
Writer

Kristin Edmonston,
Production Coordinator