UHC – Genetic and Molecular Testing Prior Auth. Requirement

August 2017 ~

Effective November 1, UnitedHealthcare (UHC) will start its online prior authorization/notification program for genetic and molecular testing performed in an outpatient setting for fully insured UHC Commercial Plan members.

UHC notes that while this program will be national, laboratory services ordered by Florida network providers for fully insured UHC Commercial Plan members in Florida will not have to participate in this requirement due to their participation in the UHC Laboratory Benefit Management Program.

Providers requesting laboratory testing will be required to complete the prior authorization/notification process. The process will require providers to indicate the laboratory and test name for the following services:

  • Tier 1 Molecular Pathology Procedures
  • Tier 2 Molecular Pathology Procedures
  • Genomic Sequencing Procedures
  • Multianalyte Assays with Algorithmic Analyses that include Molecular Pathology Testing
  • CPT codes included in the prior authorization:
    • 0001U
    • 0004M
    • 0008M
    • 81161
    • 81421
    • 81423
    • 81479
    • 81507
    • 81519
    • 81545
    • 81599

Clinical information may be requested to determine if the request meets UHC’s clinical policy requirements for coverage; requests that meet UHC clinical criteria will be granted an authorization at the time of the request. UHC will only authorize payment for those CPT codes that have been registered with the Genetic and Molecular Testing Prior Authorization/Notification Program for each specified genetic test.

CPT ® is a registered trademark of the American Medical Association.


Source(s): UnitedHealthcare Network Bulletin;