Highmark has partnered with eviCore to manage molecular/genomic, and (effective August 1, 2021) non-molecular testing within the Laboratory Management Program. The Laboratory Management Program utilizes evidence-based policies, developed with trained experts, to ensure that the lab services provided to Highmark's members support clinically appropriate care and are medically necessary, in accordance with their benefit policy.
Highmark requires prior authorization for several molecular/genomic tests when performed in an outpatient setting for fully-insured Commercial, Affordable Care Act (ACA) and Medicare Advantage members.
These tests include:
- Hereditary Cancer Screening
- Carrier Screening Tests
- Tumor Marker/Molecular Profiling
- Hereditary Cardiac Disorders
- Cardiovascular Disease And Thrombosis Risk Variant Testing
- Pharmacogenomic Testing
- Neurologic Disorders
- Mitochondrial Disease Testing
- Intellectual Disability/Developmental Disorders
Effective for dates of service beginning on August 1, 2021, Highmark requires claims review for several non-molecular tests when performed in an outpatient setting for fully insured Commercial, Affordable Care Act (ACA) and Medicare Advantage members. A prior authorization is not required for these tests.
These tests include:
- Cardiovascular Disease Risk Panels
- Allergy Testing
- Drug Testing
- Celiac Disease
- Vitamin D Testing
- Thyroid Testing
Highmark has adopted eviCore’s molecular/genomic, and non-molecular testing policies. Policies and a complete list of impacted procedure codes are available here.
Learn More About the Laboratory Management Program
eviCore has a dedicated webpage for Highmark providers to conveniently access evidence-based clinical guidelines, the current CPT code list, important resources and recent announcements. We encourage you to visit their site to ensure that you have the most current information.
- Lab Management Program Admin Guide (Revised June 2021) *New Information Effective August 1, 2021
This guide includes a summary of all components of the Laboratory Management Program.
In addition to this site and the eviCore webpage, you can also find any updates about the Laboratory Management Program on the Plan Central page of NaviNet and future issues of Provider News.