Most panels require PA. When panels are billed with individual codes for the genes in a panel, we review the medical necessity of each gene within that panel and typically only approves reimbursement for those genes that are medically necessary. In addition, many panels now have a panel-specific CPT code, but some labs are still billing with multiple stacked CPT codes. We will re-direct those panels billed with multiple codes to the appropriate single-CPT panel code. That way, we help ensure plans only pay claims that are appropriately coded.

Technically, all claims for CPT codes that are in scope are subject to claims review. We review the claim to make sure it received any necessary PA. In addition, we automatically apply more than 44,000 lab-specific claim rules to ensure appropriate reimbursement for medically necessary tests. The vast majority of these rules apply to low-cost, high-volume tests that are not subject to PA. 

Laboratory Management policies are written internally by expert staff and reviewed by internal and external medical advisory boards. Policies are reviewed at least semi-annually but can be updated more often if significant new evidence is identified. We consider peer-reviewed publications and guidelines from all major professional societies when creating clinical policies. Our Lab Policy book is the most comprehensive in the market, including policies that cover more than 500 genetic tests.