Genetic and Molecular Lab Testing
Security Health Plan is committed to improving the sustainability of care by ensuring high-quality, appropriate care is delivered at a fair price. Security Health Plan created a reimbursement policy for the billing of genetic and molecular testing October 1, 2021.
Effective June 1, 2022, Security Health Plan will expand the policy and the requirements for billing of genetic and molecular testing, all providers billing for unlisted genetic and molecular testing services are required to add the appropriate Concert Genetics GTU descriptor to all prior authorization requests (refer to genetic medical policies for prior authorization requirements) and to include on claim submissions. Security Health Plan highly recommends including the GTU descriptor when billing any genetic and molecular service as this will become a requirement in 2023.
Regarding claims submissions, in order to identify the genetic or molecular test being performed, the provider must submit the unique Genetic Testing Unit (GTU) descriptor provided through the Concert Genetics portal for all unlisted genetic and molecular tests. The GTU unique test descriptor should be submitted in field
- CMS 1500 – Loop 2400 SV101-07 on the electronic claim form or in the shaded of the service line in box 19 on a paper claim form (example: 2M6LG)
- UB04 – Loop 2400, SV202-7 on the electronic claim form or in the shaded area of the service line in block 80 (example: 2M6LG)
Genetic and Molecular Testing Reimbursement Policy
This policy addresses genetic and molecular testing services and applies to reimbursement for codes billed from the following sections in the CPT/HCPCS Manual:
- Molecular Pathology
- Genomic Sequencing Procedures and Other Molecular Multianalyte Assays
- Multianalyte Assays with Algorithmic Analyses
- Proprietary Lab Analysis (PLA) codes
Refer to Security Health Plan Genetic Testing Medical Policies for clinical criteria requirements, e.g. prior authorization.
All providers billing for genetic and molecular testing services must bill according to the following requirements; if not billed appropriately, claims may be denied.
- Bill for the test performed as indicated on the test requisition form
- If a test qualifies for panel code(s), the panel code must be used.
- If a panel code is not appropriate (or when medical policy exclusively covers components of panels), a limited number of individual components from multi-gene tests may be billed
- Codes are determined based on the attributes of the testing performed, not based on the clinical indication of the member
- Coding must be consistent with AMA coding guidelines, as interpreted by the Concert Genetics coding engine (link to concert genetics website)
- Include ordering provider information on all claim transactions
- Include Concert Genetic assigned unique test ID (GTU descriptor) when billing unlisted genetic and molecular test.
- NOTE: Security Health Plan highly recommends including the GTU descriptor when billing any genetic and molecular service as this will become a requirement in 2023.
All laboratories billing for genetic and molecular testing services must register using the Concert Genetics portal. Please visit the Concert Genetics website to:
- Verify accuracy of test catalog and review coding engine standards for each test covered by this policy
- Complete a brief quality profile
Security Health Plan currently allows pass-through billing for laboratory services, but clinics/facilities are strongly encouraged to only bill for laboratory services they provide. If a clinic/facility bills for a genetic or molecular test performed by an independent laboratory, they should bill in accordance with Concert Genetics’ coding recommendation for the performing laboratory and append the 90 modifier.
Security Health Plan requires that all providers billing for genetic and molecular testing services bill according to the coding recommendation in the Concert Genetics portal. Non-compliance with this policy will result in a written notification from Security Health Plan. Continued non-compliance may result in a denied reimbursement or termination of the provider’s contract.