Point32 Molecular Diagnostic Testing Prior Authorization (PM) Form

Harvard Pilgrim’s Molecular Diagnostic Testing Authorization Program

Harvard Pilgrim’s Molecular Diagnostic Testing authorization program is managed through an arrangement with Carelon Medical Benefits Management (formerly AIM Specialty Health).

Included Services:

• Reproductive Carrier Screening and Prenatal Diagnosis
• Preimplantation Genetic Testing, including embryo biopsy (CPT 89290, 89291)
• Testing for Single-Gene and Multifactorial Conditions
• Whole Exome/Genome Sequencing
• Hereditary Cancer Susceptibility Testing
• Hereditary Cardiac Disease Testing
• Molecular Testing of Solid and Hematologic Tumors and Malignancies (Including tumor markers)
• Pharmacogenetic and Thrombotic Disorders Testing

Effective May 2020, Genetic Counseling is no longer required for Harvard Pilgrim Members, except for Whole Genome Sequencing (CPT 81425, 81426, 81427).

Transplant testing (HPA/HLA typing) does not require a prior authorization from Carelon.

Post-transplant Chimerism analysis (CPT 81267, 81268) does require a prior authorization from Carelon.

Carelon Medical Benefits Management

Carelon is an NCQA certified and URAC accredited specialty benefits management company. Carelon promotes appropriate use of specialty care services through the application of widely accepted clinical guidelines delivered via an innovative platform of technologies and services.

Note: Refer to Point32Health Medical Necessity Guidelines: Comprehensive Genomic Profiling with FoundationOne®CDx or FoundationOne®Liquid CDx to Guide Cancer Treatment in Patients with Advanced Cancer for Clinical Coverage Criteria used for review of FoundationOne CDx and FoundationOne Liquid CDx coverage requests and authorizations: cgp-w-foundation-one

Action Required-Ordering Provider

The ordering clinician is responsible for starting the Carelon prior authorization process on or prior to the sample collection date and before the sample is tested. If the authorization request is called in on the sample collection date, the ordering provider must wait for approval before sending the member for testing.

Failure to notify Carelon in advance of a service that requires prior authorization will result in payment denial. In this scenario, members may not be balance billed and are responsible only for their applicable copayments, and/or coinsurance.

HARVARD PILGRIM HEALTH CARE-PROVIDER MANUAL

D.47 March 2023

Harvard Pilgrim Health Care a Point32Health company

Referral, Notification, and Authorization-Authorization

Authorizations can be requested on-line 24/7 at www.providerportal.com or by telephone at 855-574-6476 (Mon. – Fri., 8 a.m. – 5 p.m. EST).

Information Required

The following information will be requested from the ordering clinician’s office by Carelon and should be available at the time of the call:

• Ordering physician name, office phone, mailing address, fax number, TIN and NPI
• Office administrative or clinical contact name or direct line/extension number
• Patient’s name, date of birth and Harvard Pilgrim identification number
• Planned test(s)
• Reason for test(s)

Further evaluation
Rule out disorder
Baseline for new treatment
Evaluation of current therapy or treatment

• Sample Collection Date
• Date testing is expected to begin
• A valid, specific ICD-10 diagnosis code that represents the condition for which test is being ordered
• Name, address, TIN and NPI of lab where the test(s) will be run
• Diagnosis and clinical information pertinent to test ordered

Action Required-Servicing Provider

The servicing lab should confirm that the ordering clinician has completed the prior authorization process before providing services by requiring evidence of an approved Carelon transaction number.

Molecular Diagnostic tests should be performed only when an approved Carelon transaction number is verified.

If a servicing lab conducts a Molecular Diagnostic test for which prior authorization was not completed or denied, the procedure will not be reimbursed by Harvard Pilgrim, and the member cannot be billed.

If prior authorization is not obtained by the ordering provider prior to the test date, the prior authorization will be denied for failure to notify, the procedure will not be reimbursed by Harvard Pilgrim, and the member cannot be billed

Carelon Response

When the authorization process is completed, a transaction number will be issued. Carelon will also send written confirmation of approval and denial decisions to the member, ordering provider and servicing lab.

The approval will contain the following information:

• Approved transaction number
• Planned test(s)
• Servicing Provider (Lab)
• Date of sample collection
• Authorization validity dates
• ICD-10 Diagnosis

HARVARD PILGRIM HEALTH CARE-PROVIDER MANUAL

D.48 March 2023

Harvard Pilgrim Health Care a Point32Health company

Referral, Notification, and Authorization-Authorization

Denial letters will contain information needed to assist the member in understanding the reason(s) for the denial, and deciding whether to appeal the decision, including:

• The specific reason(s) for the denial, including clinical justification of the decision (consistent with generally accepted standards of medical practice); discussion of the individual member’s presenting symptoms or condition, diagnosis, and specific information upon which the adverse determination was based.
• The reason(s) that criteria were not met, including a reference to the benefit provision, guideline, protocol, or other criterion on which the denial was based, and notification that the member can obtain a copy of the actual information on which the denial was based.
• Any alternative treatment options offered by Harvard Pilgrim.
• The date that written or electronic confirmation was sent.
• Instructions as to how the member and/or physician can obtain a copy of the criteria used to make the determination.
• A description of appeal rights, including the right to submit written comments, documents, or other information relevant to the appeal; and an explanation of the appeal process including the right to member representation and timeframes for deciding appeals.

Status Inquiry

Electronic Servicing providers can use electronic channels to determine if authorization has been completed.

Status and transaction numbers can be accessed through Carelon’s website, www.providerportal.com. Refer to Carelon’s website, www.carelon.com, for Carelon registration information.

Phone Option

Providers may also check the status by phone at 855-574-6476.

Notification Changes

Carelon must be notified by telephone if any change to the original authorization occurs, such as a change to the test(s), a change to the testing lab or a change to the date of service. Any changes to the authorization must be made prior to the service commencing and prior to authorization expiration date. No changes will be allowed after the authorization has expired.

Any changes to the test(s) will require a new authorization and medically necessity review be completed.

Any requests to change the servicing provider and/or date(s) of service after the authorization start date must be made by contacting the Provider Service Center at 800-708-4414 and select the option for the Referral/Authorization Unit.

HARVARD PILGRIM HEALTH CARE-PROVIDER MANUAL

D.49 March 2023

Harvard Pilgrim Health Care a Point32Health company

Referral, Notification, and Authorization-Authorization