CurrentBluecross IdahoPolicy N/A

Program Overview and Administration

Describes the administration and operational requirements for prior authorization of genetic testing for Blue Cross of Idaho members through Carelon, including which tests/settings are included/excluded, who must request authorization, how to submit requests, timelines, and portal/phone contact details. Applies to tests performed on or after the program effective date.

Policy Summary

PayerBluecross Idaho

PolicyProgram Overview and Administration

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionOrdering clinicians must submit authorization requests through the Carelon provider portal or by phone prior to collecting specimen/testing; failure to obtain authorization may result in claim denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes for this update.

6Example testing categories included

3Settings excluded

4Member groups excluded

Program overview and administration

Blue Cross of Idaho has contracted Carelon to conduct prior authorization review of genetic testing requests to support evidence-based testing at in-network laboratories. Carelon will review each requested test and the clinical information submitted to ensure alignment with evidence-based clinical appropriateness guidelines that form the basis of Blue Cross of Idaho's medical policy. The program scope includes administration and operational requirements for prior authorization of genetic testing through Carelon, identifying which tests and settings are included or excluded, who must request authorization, submission methods (portal/phone), timelines, and contact details.

Authorization requirements and scope

Authorization requirement for genetic testing

Authorization is required when ALL of the following are met:

Ordering clinician must request authorization through Carelon for genetic testing for applicable Blue Cross of Idaho members

Request must be submitted prior to testing (requests after testing may be denied)

Complete date of service with specimen collection date

Tests must be ordered for members included in the program (see included/excluded member groups)

Selected laboratory must be in-network to enable real-time approval

Out-of-network labs may have different benefits or lower payment

Members requiring authorization

Authorization through Carelon is required for ALL of the following member types unless excluded:

Medicare Advantage members

Check member benefits and eligibility to determine whether authorization is required

Members excluded from the program (do not require Carelon authorization)

The program does not include the following member groups or test categories:

Excluded member groups

All Commercial members
Medicaid members
Federal Employee Plan (FEP) members

Test categories excluded

Hereditary cardiac testing
Neurogenetic and neuromuscular testing

Settings excluded from the Genetic Testing Program

Requests for tests performed in the following settings are excluded from Carelon program management:

Inpatient studies

Studies performed as part of ER/observation visit

Studies that are a component of outpatient elective surgery

Tests included in program management

The program includes, but is not limited to, the following testing types:

Reproductive carrier screening

Prenatal testing

Rare disease testing

Whole exome/genome sequencing

Hereditary cancer testing

Tumor markers

Tier one and tier two molecular pathology CPT codes (managed)

Authorization decision and appeal process

Decisions and next steps:

Requests that meet criteria are authorized in real time or within one business day when complete information is provided

Most requests are closed within one business day when information supplied

If request cannot be approved at intake, program personnel (genetic counselors and physicians) will support rapid resolution and may offer peer-to-peer review before adverse determinations

Program personnel include genetic counselors and physicians; peer-to-peer review is offered before adverse determinations

Denial letters include appeal instructions for providers and members

Providers may call Blue Cross of Idaho to appeal

What ordering clinicians must do

Prior Authorization

Obtain authorization through Carelon before testing

Ordering clinicians must obtain prior authorization through Carelon before collecting specimens or performing genetic tests. Claims for genetic tests performed on or after the program effective date will not be paid if authorization was not obtained through the Blue Cross of Idaho Genetic Testing Program. Failure to obtain authorization may result in claim denial.

Documentation Required

Enter date of service as specimen collection date

When submitting an authorization request, enter the Date of Service as the specimen collection date. Completing this field with the collection date facilitates approvals and aligns with program requirements; requests submitted after testing may be denied.

Billing Rule

Use in-network laboratory for real-time approval

Select an in-network laboratory when ordering genetic testing to enable real-time approvals. Out-of-network laboratories may have different benefits or lower payment and may appear as out-of-network in the portal; verify network status if needed.

Denial Risk

Post-service authorization risk

Requests submitted after testing may be denied. Claims for genetic tests performed without prior authorization will not be paid under the Blue Cross of Idaho Genetic Testing Program.

Documentation Required

Keep order number and determination notification

Order numbers and determination letters are provided after review and are mailed to the ordering provider, servicing provider and patient. Order numbers are also available immediately in the Blue Cross of Idaho provider portal and the order summary will note the authorization validity period (typically 90 days).

Prior Authorization

Where to submit requests

Submit new or updated authorization requests via the Blue Cross of Idaho provider portal or by phone to Carelon. Portal access provides real-time processing and order summaries.

Portal path: Authorization & Notification -> Prior Authorization Look Up Tool
Carelon phone: 866-714-1105 (Mon–Fri, 8 a.m. - 6 p.m. MT)
Portal support: 800-252-2021

Step Therapy

Peer-to-peer and clinical review options

If a request cannot be approved at intake, Carelon clinical staff (including genetic counselors and physicians) will work with providers to resolve issues. Providers may provide additional clinical information, consider alternate tests suggested, and request a peer-to-peer discussion with a physician reviewer before any adverse determination.

Turnaround times, validity, and FAQs

Timing & Thresholds

Authorization validityTypically 90 days (valid timeframe noted in order summary)

Urgent request turnaroundResponse within 72 hours of receipt

Routine request turnaroundReal time if clinical criteria met; most requests closed within one business day when information supplied

Who must submit review requests? Only ordering physicians and their staff members may submit review requests; servicing/laboratory providers should verify that authorization has been obtained prior to performing tests.

What if a test is not found in the portal? You can manually add a test by entering the test name, associated CPT codes, and, in some cases, the genes associated with the test. If unable to locate the test or diagnosis, contact Carelon Customer Service at 800-252-2021 or Blue Cross of Idaho for assistance.

How long is an order number valid? The order summary will note the valid timeframe for an authorized test; typically authorizations are valid for 90 days.

What are the case status definitions? Case status notifications indicate the overall determination and include: In Progress (pending Carelon clinical review), Completed (reviewed and an order number issued), Authorized (approved), Non-Authorized (denied/not meeting medical necessity), Voluntarily Cancelled (provider withdrew the case), Not Reviewed/Error (withdrawn/duplicate/accidental entry), and Review Cancelled (identified as duplicate and previously submitted).

Key definitions

Definitions

Genetic Testing ProgramProgram administered by Carelon to manage clinical appropriateness reviews and prior authorizations for genetic testing for Blue Cross of Idaho members.

Carelon administers clinical appropriateness reviews and prior authorizations for the Blue Cross of Idaho Genetic Testing Program. Their review process is supported by a team of genetic counselors and physicians and uses evidence-based clinical guidelines to determine medical necessity.

Carelon clinical appropriateness guidelines are developed by board-certified genetic counselors and medical geneticists through systematic review of peer-reviewed resources, medical society guidelines, and practice bulletins, and are reviewed and updated at least twice annually (more frequently if new evidence requires).

OpenPayer