Posted in EmblemHealth NY, NY Providers, Training, Updates

EmblemHealth NY Medicaid and HARP members: Non-Invasive Prenatal Trisomy Screening Expanded!

Effective 11/01/2021 coverage of non-invasive prenatal trisomy screening using cell-free fetal DNA (deoxyribonucleic acid) has been expanded to include pregnant members age 30 and older.

This benefit also will include twin pregnancies, but not higher multi-gestational pregnancies


Consistent with current policy, non-invasive prenatal trisomy screening will continue to be covered when at least one of the following criteria is met:

  • Either parent has a family history of aneuploidy in a first* or second** degree relative.
  • Standard serum screening or fetal ultrasonographic findings indicate an increased risk of aneuploidy.
  • Parent(s) have a history of a previous pregnancy with a trisomy.
  • Either parent is known to have a Robertsonian translocation.

Definitions:

*First degree relatives: Parents, children, siblings
** Second degree relatives: Grandparents, aunts and uncles, nieces and nephews, and grandchildren


Note: This is an update to the October 2014 Medicaid Update article titled NYS Medicaid Now Covers Non-invasive Prenatal Testing for Trisomy 21, 18 and 13.

You can find the updated version of this policy (NY Medicaid) here.  


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Posted in #unitedhealthcare, Training, Updates

UHC Providers: Genetic testing Penalty waiver has expired!

This blog post applies to genetic/molecular testing penalty waiver, that was available to providers/labs while UHC was transitioning to a new Prior Authorization and notification Platform, in 2021.


This process finished and as of Jan 1,2022 the waiver has expired!

In order to get paid for genetic/molecular testing, providers must request a prior authorization and/or an advanced notification, for any code that requires it.


Where to request prior auth/advanced notification?

Providers must go to  Prior Authorization and Notification platform or by call 877-303-7736.

Performing laboratories can submit advance notifications.

If a test requires prior authorization with clinical criteria, the request must be submitted by the ordering provider.


For the current list of genetic and molecular tests that require prior authorization/advance notification, please go to UHCprovider.com/paan > Advance Notification and Plan Requirement Resources.


Questions?
For more information about the genetic and molecular lab testing prior authorization/advance notification program, please visit the UnitedHealthcare genetic and molecular testing prior authorization/advance notification (PAAN) web page and review the genetic and molecular lab testing PAAN FAQs.


Prior authorization/advance notification training
UnitedHealthcare is offering live training sessions for the genetic and molecular testing prior authorization/advance notification (PAAN) program. To register for training, please visit the UnitedHealthcare genetic and molecular testing prior authorization/advance notification (PAAN) web page.


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Posted in BCBS (Various States), Training, Updates

BCBS Michigan: Genetic Counselors to receive direct payment 01/01/2022

What genetic counselors do?
Genetic counselors obtain and evaluate individual, family and medical histories to determine the risk for genetic or medical conditions or diseases in a member, the member’s descendants or other family members.
Genetic counselors explain to the member the clinical implications of genetic laboratory tests and other diagnostic studies and their results.

According to BCBS of Michigan genetic counselors have an opportunity to participate in BCBS of Michigan’s Traditional and TRUST PPO networks, and BCN commercial, effective Jan. 1, 2022.

This change, effective for outpatient services provided on or after Jan. 1, applies to Blue Cross and BCN benefit plans that cover services that these providers are licensed to provide.


How to Enroll?

Genetic counselors can find enrollment forms and practitioner agreements on bcbsm.com/providers. To find enrollment information, click on Enroll to become a provider. Specific qualification requirements are identified within each agreement. All applicants must pass a credentialing review before participation. BCBS of Michigan will notify applicants in writing of their approval status.


Checking Member Benefits:

To find out if a member has coverage, check web-DENIS for member benefits and eligibility or call Provider Inquiry at 1-800-344-8525

Medical Billing:

Participating Genetic Counselors are allowed to directly bill codes to BCBS of Michigan:

*96040 and S0265, under professional services.

Reimbursement Rate:

Directly billed codes will be reimbursed at 85% of the applicable fee schedule, minus any member deductibles and copayments.

Prior Authorization Requirements:

Genetic Counseling does not require an authorization. For BCN commercial members who have a primary care physician that is part of a medical care group based in the East or Southeast region, their primary care provider must submit a referral for a specialist office visit. Referrals are not required for other members.

To learn more about BCBS of Michigan Genetic Testing and Counseling, please click here to read the full policy.


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