Genetic testing can identify alterations in an individual?s
genetic makeup that may indicate the possibility of risk
or the presence of disease (i.e., inherited or acquired)
or carrier status. In addition to its use as a possible
clinical tool for diagnostic, predictive, carrier, and presymptomatic
testing, genetic testing may be part of
the clinical work-up during the provision of prenatal or
embryo pre-implantation services, as well as newborn
screening. Genetics is an extensive and expansive field,
and due to its continuously evolving nature, a large
number of genetic tests are in the research phase of
development at this time.
Referral process
The AmeriHealth laboratory network has extensive genetic testing
capabilities; therefore, providers should refer members
only to participating laboratories for covered services.
In the unusual circumstance that a specific test and
related services are not available through a participating
laboratory, providers must contact AmeriHealth to obtain
preapproval. Preapproval is required for the use of a
non-participating laboratory.
Contractual obligation to use
participating providers
In accordance with your AmeriHealth Provider Agreement (AmeriHealth
Agreement), except in an emergency, a participating
provider should refer commercial and Medicare
Advantage HMO members only to participating providers
for covered services. This includes, but is not limited
to, ancillary services such as laboratory and radiology,
unless the provider has obtained preapproval from AmeriHealth
for the use of a non-participating laboratory.
Non-compliance may result in financial
and other implications
When applicable under the terms of your AmeriHealth
Agreement, if a provider continues the use of a nonparticipating
laboratory (such as Ambry GeneticsTM,
Boston Heart Diagnostics®, Counsyl, Inc., Good
Start®
Genetics, Ascendant MDX, Inc. (now Progenity), and
Sequenom® Laboratories) for HMO members and
does not obtain preapproval from AmeriHealth, the provider is
required to hold the member harmless. The provider will
be responsible for any and all costs to the member and
shall reimburse the member for such costs or be subject
to claims offset by AmeriHealth for such costs. In addition, further
non-compliance may result in immediate termination of
your AmeriHealth Agreement.
Exception to the use of non-participating
providers per the terms of your
AmeriHealth Agreeement
If a provider refers a member to a non-participating
laboratory for non-emergent services without obtaining
preapproval from AmeriHealth to do so, sends a member's
specimen to a non-participating laboratory without
preapproval, or provides or orders non-covered services
for a member, the provider must inform the member in
advance, in writing, of the following:
- a list of the services to be provided;
- that AmeriHealth will not pay for or be liable for the listed
services;
- that the member will be financially responsible for such
services.
Providers should also be aware of the coverage status
of the tests they order and should notify the member
in advance if a service is considered experimental,
investigational, or non-covered by AmeriHealth. To view our
coverage position on specific genetic tests, please refer to the current
version of Medical Policy #06.02.35: Genetic
Testing.
Note: Members who have out-of-network benefits
may choose to use a non-participating laboratory for a
medically necessary service, but they will have greater
out-of-pocket costs associated with that service. In
addition, the member will be financially responsible for
the entire cost of any service that is non-covered (e.g., a
service that is considered experimental/investigational).
If you have any questions related to the referral process
for genetic testing, please contact your Network
Coordinator or Hospital/Ancillary Services Coordinator.