Highmark contracts with eviCore to manage molecular and genomic testing within a new Laboratory Management Program. The Laboratory Management Program utilizes evidence-based policies, developed with trained genetic experts, to ensure that the genetic lab services provided to Highmark's members support clinically appropriate care and are medically necessary, in accordance with their benefit policy.
Effective with dates of service on or after August 1, 2016, Highmark requires prior authorization for several molecular and genomic tests when performed in an outpatient setting for fully-insured Commercial, 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 Aug. 1, 2016, claims associated with molecular and genomic procedure codes will be reviewed for accuracy and medical necessity prior to payment, based on eviCore's policies. This review is not limited to only those codes for which authorization is required. Any services performed without a prior authorization may be denied, and providers may not seek reimbursement from members.
Learn More About the Laboratory Management Program
eviCore has a dedicated webpage for Highmark providers to conveniently access the most up-to-date announcements, clinical guidelines, and procedure code lists for prior authorization and claims review. We encourage you to visit their site to ensure that you have the most current information.
eviCore is a is a separate company that works with Highmark to administer the Lab Management Program. eviCore does not provide Blue Cross and/or Blue Shield products or services. eviCore is solely responsible for the products and services described here.
Last updated on 1/24/2018