We’re committed to working with consumers and care providers to support improved population health outcomes, positive care experiences and affordable products. An increasingly important part of this commitment includes coordinating coverage guidelines and policies for new and emerging technologies, including genetic testing.
By working with you, we can provide access to this emerging field and promising new treatments for patients while balancing patient safety and clinical evidence. Our new online notification/prior authorization process for genetic and molecular lab tests will help provide access while supporting a better care experience for members and care providers.
The notification/prior authorization requirement for certain genetic and molecular tests applies to:
- Certain UnitedHealthcare commercial benefit plans when UnitedHealthcare is the primary payer
- UnitedHealthcare Community Plan in select states
Ordering care providers will complete the notification/prior authorization process online or over the phone. Labs must register their tests to participate as part of the Genetic and Molecular Lab Testing Notification/Prior Authorization process
Notification/Prior Authorization Required
Notification/prior authorization for genetic and molecular tests has been required for certain UnitedHealthcare commercial benefit plans since Nov. 1, 2017, for UnitedHealthcare of the Mid- Atlantic, Inc. benefit plan members since April 1, 2018, and for UnitedHealthcare Plan of the River Valley, Inc., UnitedHealthcare Insurance Company of the River Valley since July 1, 2019.
UnitedHealthcare requires that care providers complete the notification/prior authorization process for genetic and molecular testing performed in an outpatient setting for UnitedHealthcare Community Plan members in these states:
- Beginning Feb. 1, 2019: Maryland, Michigan, Missouri, New York, Tennessee and Texas
- Beginning March 1, 2019: Florida
- Beginning April 1, 2019: New Jersey, Rhode Island
- Beginning Feb. 1, 2020 : Pennsylvania
Genetic and Molecular Lab Testing Notification/Prior Authorization Process Not Required
The Genetic and Molecular Lab Testing Notification/Prior Authorization requirement does not apply to members in the following types of UnitedHealthcare and affiliate health plans. Even though they’re not included in the Genetic and Molecular Lab Testing Notification/Prior Authorization requirement, the listed plans may still require prior authorization for genetic and molecular tests. You can find plan-specific prior authorization requirements in our medical policies and prior authorization lists.
- All UnitedHealthcare Medicare and Medicare Advantage plans, including Dual Special Needs Plans (DSNP)
- These specific commercial plans
- All Savers Insurance Company
- All Savers Life Insurance Company of California
- Golden Rule Insurance Company
- MAMSI Life and Health Insurance Company
- MD-Individual Practice Association, Inc.
- Neighborhood Health Partnership, Inc.
- Optimum Choice, Inc.
- Oxford Health Insurance, Inc.
- PacifiCare Life and Health Insurance Company
- Sierra Health and Life Insurance Company, Inc.
- UnitedHealthcare West
When you submit or review a notification/prior authorization request in the Genetic and Molecular Test tool in Link, you may see a “case status” listed. Here’s what the status means:
- Approved. The case has been completed and a notification/authorization has been provided for the selected treatment.
- Incomplete. The case has been started, but not finished. All cases that are incomplete will give the ordering care provider the option to “Resume” or “Cancel” the request.
- “Resume” returns you to the last completed question in the request. You can get back into your incomplete request for 14 days, after which the request will expire. If you still need a notification/prior authorization, you’ll have to submit a new request.
- "Cancel” withdraws the request.
- Pending Clinical Review. The case has been submitted and is under clinical review. We’ll contact you if more information or a physician-to-physician discussion is required.
- Pending Registration. Your request was received and BeaconLBS, our vendor managing this process, is contacting the requested laboratory for additional information.
- Withdrawn. You canceled the request. If you still need a notification/prior authorization, you’ll have to submit a new request.
- Expired. The case is no longer active. This is a system status; an incomplete request was not completed within 14 days.
- Non-certified. The medical review determined that the requested treatment was unproven.
The following genetic and molecular tests are included in the notification/prior authorization requirement:
The following will require notification/prior authorization:
- Tier 1 Molecular Pathology Procedures
- Tier 2 Molecular Pathology Procedures
- Genomic Sequencing Procedures
- Multianalyte Assays with Algorithmic Analyses that include Molecular Pathology Testing
- These CPT® codes:
- 0012U 0014U
- 0016U 0019U
- 0022U 0023U
- 0026U 0034U
- 0036U 0037U
- 0045U 0050U
- 0055U 0057U
- 0069U 0076U
- 0087U 0091U
- 0101U 0103U
- 0129U 0138U
- 0153U 0162U
- 0006M 0007M
- 0011M 0013M
- 81105 81111
- 81120 81121
- 81161 81210
- 81215 81420
- 81425 81479
- 81518 81521
- 81595 81599
We’ll use the following medical policies to review requests for genetic and molecular testing:
- Carrier Testing for Genetic Diseases
- Chromosome Microarray Testing (non-oncology)
- Fetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood
- Genetic Testing for Cardiac Disease
- Genetic Testing for Hereditary Cancer
- Genetic Testing for Neuromuscular Diseases
- Molecular Oncology Testing for Cancer Diagnosis, Prognosis and Treatment Decisions
- Pharmacogenetic Testing
- Pre-implantation Genetic Testing
- Whole Exome and Whole Genome Sequencing
To view the latest policy information, please visit the Policy section at UHCprovider.com/policies.
If you have questions about the notification/prior authorization process, about using the online tools, or want to complete the notification/prior authorization process over the phone call us at 800-377-8809. Representatives are available Monday - Friday from 7 a.m. to 7 p.m.