Reimbursement Policy Genetic Testing: Once per Lifetime
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This policy governs Blue Cross NC reimbursement for specific germline genetic sequencing procedures limited to once per member lifetime and affects providers submitting claims to Blue Cross and Blue Shield of North Carolina (including Healthy Blue Medicaid).
Updated Related Coding section by adding codes.
Coverage Criteria
Once-per-lifetime coverage stance
Covered when ALL of the following are met:
Genetic tests eligible for once-per-lifetime reimbursement
Specific genetic sequencing procedures eligible for reimbursement once per member lifetime:
Related Coding
| Genetic sequencing once-per-lifetime procedures (see Related Coding link) |
Provider Actions & Billing
Authorization, medical necessity, and documentation required
Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and the member's state of residence. Use proper billing and submission guidelines and ensure services billed with CPT, HCPCS, and/or revenue codes are fully supported in the medical record and/or office notes; failure to follow coding/billing guidelines may result in claim rejection, denial, or recovery/recoupment of payment.
- Verify prior authorization and medical necessity per the member's plan and state requirements before performing sequencing.
- Document the procedure, diagnosis, and supporting clinical information in the medical record or office notes to substantiate the billed codes.
- Bill using industry-standard CPT, HCPCS, and/or revenue codes and follow proper submission guidelines.
No balance billing for members
This reimbursement policy change affects provider billing and reimbursement; providers must not balance bill members for amounts not covered due to this policy.
- Do not seek additional payment from members for services limited by this once-per-lifetime reimbursement policy.
- Monitor Related Coding updates (codes added 10/23/2025) to ensure accurate claim submission and compliance with the policy effective date.
Definitions
Not Covered
Repeat sequencing of a member's germline genotype during their lifetime is not covered. The plan recognizes that the germline genotype does not change during a member's lifetime, and therefore additional sequencing for the same germline genotype is not medically necessary and will not be reimbursed.
Separate reimbursement for reinterpretation of previously obtained sequencing results is not covered. While variant classifications and interpretations may change over time, re-sequencing is not required for reinterpretation and the plan does not provide an additional payment for re-analysis of original results.
This policy applies to the genetic sequencing procedures listed in the Related Coding section, which are limited to one reimbursement per member lifetime. Providers must follow applicable authorization and medical necessity requirements and may not balance bill members as a result of this reimbursement policy.
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