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Insurance and Billing Information for Genetic/Genomic Testing

Coverage


BRAC1 and BRCA2 Screening and the High Risk Hereditary Breast Cancer Panel

Medicare

Medicare pays for genetic testing when the test is considered medically necessary and the criteria in applicable Local Coverage Determination policies are met. Medicare claims for services performed at Baylor Genetics Laboratory are processed by the Medicare Administrative Contractor (MAC) for the state of Texas, Noridian Solutions, LLC.

Providers should consult the MCR TX LCD for BRCA1 and BRCA2 to determine if their patient meets criteria for genetic testing before ordering testing.

For Medicare patients that do not meet medical criteria, the patient must complete an Advanced Beneficiary Notice of Non-coverage (ABN form) and this form must be submitted to Inform Diagnostics before testing will begin. Because Medicare will likely not cover test costs for patients who do not meet Medicare criteria, test costs will be billed to the patient. A summary of instructions for Medicare patients is included on the ABN

Commercial Payors

Aetna
Aetna requires that patients meet coverage criteria to be eligible for BRCA1 and BRCA2 Screening and the High Risk Hereditary Breast Cancer Panel and the tests to be pre-authorized. For prior-authorization, Aetna requires the Aetna Prior Authorization Request form to be completed. Inform Diagnostics will facilitate the authorization request once the specimen, completed requisition, insurance information and clinical notes are received. If Aetna denies testing, the physician will be notified.

United Healthcare and Cigna
United Healthcare and Cigna United Healthcare and Cigna require that patients undergo genetic counseling to determine medical criteria eligibility for BRCA1 and BRCA2 Screening and the High Risk Hereditary Breast Cancer Panel. Following the completion of genetic counseling, prior-authorization is required.

Inform Diagnostics will facilitate counseling with an independent genetic counselor and prior-authorization upon receipt of specimen, completed requisition and insurance information. If United Healthcare or Cigna denies testing, the healthcare provider will be notified.

Breast Cancer Gene Mutation Panel

Coverage of genetic/genomic testing by insurance providers varies greatly depending on payor policy, patient plan, patient medical condition etc. Prior authorization is required and will be performed by Inform Diagnostics before testing is initiated. Please see the section below for Inform Diagnostics' Genomic Testing Policy.

Genomic Testing Policy


To protect patients, Inform Diagnostics follows the policy below when billing insurance for genetic testing:

  • Testing will be on hold until Inform Diagnostics completes the verification of benefits or prior-authorization with insurance provider. This process averages from 2–15 days.
  • If testing is covered by insurance provider, Inform Diagnostics will proceed if the patient responsibility is estimated to be less than $100. The patient will be financially responsible for any amounts not covered, such as a co-pay or deductible.
  • If the patient responsibility is estimated to exceed $100, Inform Diagnostics will contact the patient to determine how to proceed and if testing should be performed or cancelled.

If a patient has questions about a bill from Inform Diagnostics, please call us at 1.800.344.1160

We have worked with Miraca for more than a year, and they have been incredibly helpful and efficient!
— Susan Seidel, RN,
Office Manager, Stone Oak Dermatology, San Antonio, Texas


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