CurrentCommunity Health Plan WashingtonPolicy N/A

CONCERT GENETIC TESTING: IDENTITY AND FORENSICS

This policy governs coverage of genetic testing performed to confirm the identity or provenance of laboratory specimens (forensics/know‑error) for members of Community Health Plan Washington and affiliated Centene health plans.

Policy Summary

PayerCommunity Health Plan Washington

PolicyCONCERT GENETIC TESTING: IDENTITY AND FORENSICS

Policy CodePolicy N/A

Change TypeRevised (stance reworded) + Added (new standalone policy)

Effective DateN/A

Next Review DateN/A

Key ActionVerify coverage and prior authorization requirements; submit appropriate coding and documentation when seeking coverage.

SourceLink

POLICY UPDATE CHANGES

Reworded stance from calling the test 'investigational' to stating that 'current evidence does not support' separate genetic testing to confirm specimen identity.

New standalone policy created for identity and forensics testing; criteria previously in Concert Genetic Testing: Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies were moved into this policy.

1primary policy statements

81265,81266,81479example CPT codes

noneNCCN guidance

Coverage Criteria for Specimen Identity Testing

Genetic Testing to Confirm the Identity of Laboratory Specimens

Covered when ALL of the following are met

Primary policy statement: Current evidence does not support genetic testing to confirm the identity of laboratory specimens (e.g., know error) when billed separately for all indications because it is generally considered part of the genetic testing process for quality assurance.

See rationale and coding table for examples (e.g., Know Error DNA Specimen Provenance Assay).

The plan's position is that genetic testing to confirm the identity of laboratory specimens (for example, Know Error DNA Specimen Provenance Assays) is not supported when billed separately. Current evidence does not support separate coverage because specimen identity confirmation is generally considered part of laboratory quality assurance and the genetic testing process.

Performing and billing genetic tests solely to confirm laboratory specimen identity is considered not supported by current evidence and may be deemed not medically necessary when submitted as a separate service. Providers seeking coverage for such testing should be aware that this policy does not provide coverage criteria for separately billed identity testing.

Coding References and Identifiers

Policy Summary

PayerCommunity Health Plan Washington

PolicyCONCERT GENETIC TESTING: IDENTITY AND FORENSICS

Policy CodePolicy N/A

Change TypeRevised (stance reworded) + Added (new standalone policy)

Effective DateN/A

Next Review DateN/A

Key ActionVerify coverage and prior authorization requirements; submit appropriate coding and documentation when seeking coverage.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Actions, Billing, and Documentation

Denial Risk

Specimen Identity Testing Not Supported Separately

Genetic testing to confirm specimen identity (e.g., Know Error / DNA Specimen Provenance Assay) is generally considered part of the laboratory's internal quality assurance process and is not supported when billed separately.

Separate billing for specimen-identity genetic testing is generally not supported and may be denied.
Verify coverage with the payer before ordering; prior authorization may be required if billing separately is attempted.
Reference current CPT coding guidance and the Concert Platform for registered tests prior to claim submission.

Prior Authorization

Provider Action Required

Before submitting claims, confirm payer-specific coverage rules. If a provider believes a specimen-identity test is necessary and distinct from routine laboratory quality processes, obtain prior authorization and document the clinical rationale thoroughly in the medical record.

Obtain prior authorization when attempting to bill specimen-identity testing separately.
Document the reason the test is distinct from routine laboratory QA and include supporting clinical information in the record.
If coverage is unclear, contact the payer for direction and retain written confirmation.

Documentation Required

Coding and Documentation Guidance

Providers must follow current CPT coding guidance and payer billing rules. Codes shown in the source policy (e.g., 81265, 81266, 81479 and related ICD codes) are provided for informational purposes only and do not guarantee coverage.

Reference current CPT guidance before claim submission.
Use the Concert Platform to verify registered tests and any payer-specific test mappings.

Denial Risk

Denial Risk for Separate Specimen Identity Testing

Billing the specimen-identity assay separately carries a high risk of denial because such testing is typically considered an internal QA activity rather than a separately billable clinical service.

Expect denials if the specimen-identity test is submitted as a separate, billable clinical service without prior authorization and clear documentation.
If denied, provide documentation showing why the test was medically necessary and distinct from routine laboratory QA when requesting reconsideration.

OpenPayer

CONCERT GENETIC TESTING: IDENTITY AND FORENSICS

Coverage Criteria for Specimen Identity Testing

Coding References and Identifiers

Provider Actions, Billing, and Documentation

Definitions

Background

Not Covered

81265
81266
81479