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    v1.0.30
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyAHCCCS rWGS Prior Auth Coverage | OpenPayer
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    CurrentArizona Health Care Cost Containment SystemPolicy N/A

    AHCCCS Reimbursement for Rapid Whole Genome Sequencing (rWGS)

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    This policy governs AHCCCS reimbursement for medically necessary rapid whole genome sequencing (rWGS) provided to eligible Medicaid recipients in an inpatient hospital setting. It establishes clinical eligibility, prior authorization, separate billing, and payment requirements for hospitals.

    Policy Summary
    PayerArizona Health Care Cost Containment System
    PolicyAHCCS Reimbursement for Rapid Whole Genome Sequencing (rWGS)
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateOctober 30, 2023
    Next Review DateN/A
    Key ActionObtain prior authorization before seeking separate reimbursement for medically necessary rWGS provided to an eligible inpatient recipient.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Under 1 yearMaximum recipient age for eligibility
    0094UCovered rWGS procedure code
    10/30/2023–06/30/2026Separate payment period
    CMS-1500Required claim form

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Prior authorization required
    Payment prerequisite

    Eligibility for Separate rWGS Reimbursement

    Eligibility for separate rWGS reimbursement

    Separate reimbursement is available when all of the following requirements are met:

    ALL of the following

    • Recipient eligibility

      • ALL of the following

        • The recipient is under one year of age.
        • The recipient has a complex or acute illness of unknown etiology.

    • Treatment setting

      • The recipient is receiving inpatient treatment in a hospital ICU or high-acuity pediatric care unit.

    • Test timing

      • rWGS is provided in the inpatient hospital setting prior to discharge.

    • Authorization

      • Prior authorization is obtained.

    Covered Service and Payment Parameters

    Covered rWGS HCPCS CodesHCPCSCovered
    0094UGenome testing, including unexplained constitutional or heritable disorder or syndrome, rapid sequence analysis
    Recipient age
    Eligibility requirementRecipient must be under one year of age.
    Eligible populationMedicaid recipients who meet the clinical, setting, timing, and authorization requirements.
    Separate reimbursement relevanceThe age requirement applies when seeking separate reimbursement for medically necessary inpatient rWGS.
    Clinical condition
    Qualifying conditionRecipient must have a complex or acute illness of unknown etiology.
    Clinical purposeThe illness must be evaluated through medically necessary rapid whole genome sequencing.

    Authorization, Documentation, and Billing Requirements

    Prior Authorization

    Prior Authorization Required

    Prior authorization must be obtained before seeking separate reimbursement for rapid whole genome sequencing (rWGS) provided in the inpatient hospital setting. Separate payment is available only when prior authorization is obtained and the established clinical criteria are met.

    Documentation Required

    Clinical Eligibility Documentation

    Document that the Medicaid recipient meets the clinical eligibility requirements for rWGS before submitting the claim for separate reimbursement.

    • Patient is under one year of age.
    • Patient has a complex or acute illness of unknown etiology.
    • Patient is receiving inpatient treatment in a hospital ICU or high-acuity pediatric care unit.

    Policy Terms

    Rapid whole genome sequencing (rWGS)
    TermrWGS means rapid whole genome sequencing.
    DefinitionTesting using rapid sequence analysis.
    Clinical evaluation purposeUsed to evaluate an unexplained constitutional or heritable disorder or syndrome.
    All Patient Refined Diagnosis Related Group (APR-DRG)
    TermAPR-DRG means All Patient Refined Diagnosis Related Group.
    Payment methodologyAPR-DRG is the inpatient payment methodology used to determine diagnosis-related reimbursement.
    rWGS treatment
    Policy Summary
    PayerArizona Health Care Cost Containment System
    PolicyAHCCS Reimbursement for Rapid Whole Genome Sequencing (rWGS)
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateOctober 30, 2023
    Next Review DateN/A
    Key ActionObtain prior authorization before seeking separate reimbursement for medically necessary rWGS provided to an eligible inpatient recipient.
    SourceLink
    On This Page
    Eligibility for Separate rWGS ReimbursementCovered Service and Payment ParametersAuthorization, Documentation, and Billing RequirementsPolicy Terms
    Requirement statusThe clinical condition is required for separate reimbursement.
    Treatment setting
    Eligible settingInpatient hospital ICU or high-acuity pediatric care unit.
    Treatment statusThe recipient must be receiving inpatient treatment.
    Payment relevancerWGS provided in this setting may qualify for separate reimbursement when all other criteria are met.
    Test timing
    Required timingThe test must be provided in the inpatient hospital setting.
    Discharge deadlinerWGS must be provided prior to inpatient hospital discharge.
    Additional conditionClinical criteria must be met when the test is provided.
    Separate payment period
    Start dateDates of service on or after October 30, 2023.
    End dateThrough June 30, 2026.
    Payment periodSeparate payment methodology applies during this period for qualifying inpatient rWGS testing.
    Billing Rule

    Separate Hospital Claim Submission

    Bill rWGS costs separately from the inpatient episode to obtain reimbursement outside the APR-DRG payment. The facility must submit a separate invoice on a CMS-1500 claim form with the appropriate HCPCS procedure code and report the hospital NPI as Provider Type 02 (Inpatient Hospital) in the service location field or loop.

    • Use HCPCS code 0094U for rapid genome sequence analysis and bill at the applicable AHCCCS fee schedule rate.
    • Enter the beneficiary's inpatient hospital attending provider in the rendering provider field or loop.
    • Report the rWGS ordering provider in the ordering/referring provider field or loop.
    Denial Risk

    Inpatient Timing Requirement

    The rWGS test must be provided before inpatient discharge, while the patient continues to meet the applicable clinical criteria. Testing performed after discharge or when the criteria are no longer met is not eligible for the separate inpatient reimbursement methodology.

    Qualifying inpatient rWGS testing is excluded from the APR-DRG payment and reimbursed separately at the Medicaid laboratory fee schedule amount.