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

February 2018

Reminder: Prior Authorization for Genetic Testing

As a reminder, Harvard Pilgrim currently requires prior authorization for genetic testing for Medicare Advantage members, 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 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.

Attend a provider education webinar
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.

Requesting prior authorization
The ordering clinician is responsible for obtaining prior authorization through AIM. Any genetic/genomic and molecular tests performed without prior authorization (as of January 1, 2018 for Medicare Advantage and March 1, 2018 for commercial members) 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:

  • Online at www.providerportal.com (registration instructions are available online)
  • By telephone at 855-574-6476 (Mon.–Fri., 8 a.m.– 5 p.m. EST)

For commercial members, 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 for commercial members 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
For certain genetic tests, genetic counseling may be required before the request can be authorized for commercial members. 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.

Additional information
For further details, please refer to the following:

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