eviCore healthcare will begin managing the preauthorization review of most genetic testing for dates of service on or after April 1, 2019. eviCore will review preauthorization requests for all ConnectiCare Medicare Advantage and commercial plans.
eviCore will apply nationally-accepted criteria in its medical necessity review. This partnership will provide you with clinical expertise in the growing molecular and genomic testing field to help ensure that your patients get the right genetic tests.
Reviews will apply to non-emergent outpatient diagnostic services. No preauthorization review is required for services performed in an emergency room, inpatient hospital or observation stay.
Preauthorization reviews by eviCore will include genetic testing for:
- Hereditary cancer syndromes
- Carrier screening
- Tumor marker/molecular profiling
- Hereditary cardiac disorders
- Cardiovascular disease and thrombosis risk variant
- Pharmacogenomics
- Neurologic disorders
- Mitochondrial disease
- Intellectual disability/developmental disorders
ConnectiCare will continue to manage preauthorization reviews for preimplantation genetic testing. The process for those submissions and reviews remains the same.
For a complete list of affected Current Procedural Terminology (CPT) codes that require preauthorization or information on how to submit requests, go to www.evicore.com/healthplan/connecticare. This website also includes details on what information is required with preauthorization requests and clinical guidelines.
There are two ways to submit preauthorization requests for genetic testing after April 1, 2019:
- Online at www.evicore.com/healthplan/connecticare, available 24 hours, seven days a week. You can submit standard and urgent requests through this website.
- Call eviCore at 888-835-2042 from 7 a.m. to 7 p.m. Eastern Time (ET), Monday through Friday.
Any genetic testing performed without prior authorization may be denied for payment, and you may not seek reimbursement from our members.
