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Referring members for genetic testing

July 1, 2014

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

IBC?s 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 IBC to obtain preapproval. Preapproval is required for the use of a non-participating laboratory.

Contractual obligation to use participating providers

In accordance with your IBC Provider Agreement (IBC 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 IBC for the use of a non-participating laboratory.

Non-compliance may result in financial and other implications

When applicable under the terms of your IBC 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 IBC, 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 IBC for such costs. In addition, further non-compliance may result in immediate termination of your IBC Agreement.

Exception to the use of non-participating providers per the terms of your IBC Agreeement

If a provider refers a member to a non-participating laboratory for non-emergent services without obtaining preapproval from IBC 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 IBC 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 IBC. 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.


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