CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Genetic Testing Prior Authorization Form — Coverage Criteria

Form and requirements for prior authorization of genetic and molecular tests for Neighborhood Health Plan of Rhode Island members; governs providers seeking authorization for genetic tests that may affect clinical management.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyGenetic Testing Prior Authorization Form — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and return the Genetic Testing Prior Authorization Form to Utilization Management with required member, provider, test details and clinical justification showing how results will change management.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 pageform length

Physiciansignature requirement

401-459-6023UM contact

Auth not guaranteepayment caveat

Coverage Criteria

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyGenetic Testing Prior Authorization Form — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Clinical utility and sensitivity: Test must be for the benefit of the member such that the results will impact and change the member's clinical management.sensitivity > clinical pre-test probability

From clinical information section; sensitivity must exceed pre-test probability (source chunk 3).

Test type specification: Provider must state whether the requested test is for a specific genetic defect (e.g., Fragile X) or is a screening test (e.g., microarray) and provide a description.

Medical necessity question 1 (source chunk 4).

Justification of impact—positive result: Provider must describe how a positive test result will affect the member's clinical management.

Medical necessity question 2 (source chunk 4).

Justification of impact—negative result: Provider must describe how a negative test result will affect the member's clinical management.

Medical necessity question 3 (source chunk 4).

Regulatory status: Provider must indicate whether the requested test is FDA approved.

Medical necessity question 4 (source chunk 4).

Covered Indications

Genetic test expected to impact member clinical management

Clinical utility explanation: Provider must explain why the requested genetic test is expected to change the member's clinical management, including specific actions that would follow positive and negative results.

See clinical information and medical necessity questions 2 and 3 (source chunks 3 and 4).

Sensitivity requirement: The sensitivity of the requested test must be greater than the clinical pre-test probability of the diagnosis.sensitivity > clinical pre-test probability

Explicit sensitivity > pre-test probability requirement (source chunk 3).

Provider Actions & Submission Requirements

Prior Authorization

Prior Authorization Submission

Prior authorization required — complete and return the Genetic Testing Prior Authorization Form to Neighborhood Health Plan of Rhode Island Utilization Management. Submit via fax to (401) 459-6023. Refer to Neighborhood's Clinical Medical Policy on www.nhpri.org for detailed benefit, authorization, and coverage criteria.

Return completed form to Utilization Management at (401) 459-6023
See Neighborhood Clinical Medical Policy at www.nhpri.org for coverage criteria

Step Therapy

No step therapy requirements are listed on the Genetic Testing Prior Authorization Form.

Documentation Required

Required Identifying & Test Documentation

Required identifying and test documentation must be provided on the form. Include complete member and provider details, test codes, and laboratory information to support the request.

Member name, ID number, and date of birth
Provider name, Supplier ID or NPI, provider phone/fax, and contact name
Date of request and requested date of service; place of service/facility
CPT code(s) and units, diagnosis and diagnosis code
Genetic test name and test code (if applicable); laboratory name, contact, address, phone and fax

Documentation Required

Clinical Justification

Clinical justification must explain why the test is medically necessary and how the results will change the member's clinical management. Describe whether the test targets a specific genetic defect or is a screening test, and indicate the expected impact of positive and negative results. State if the test is FDA approved.

Explain whether the test is for a specific defect (e.g., Fragile X) or a screening test (e.g., microarray)
Describe how a positive result will alter clinical management
Describe how a negative result will alter clinical management
Provide clinical pre-test probability and demonstrate test sensitivity exceeds pre-test probability
Indicate whether the test is FDA approved

Documentation Required

Signature Requirement

The form must be signed and dated by the treating physician. Only a physician signature will satisfy the signature requirement for submission.

Signature of treating physician and date are required
Who may sign/order: treating physician (physician signature reiterated)

Denial Risk

Authorization / Payment Risk

Authorization decisions do not guarantee payment. If a request is not approved, a letter will be sent. Authorization details (authorization number, dates of service, approval status) will be documented by Neighborhood.

Authorization is not a guarantee of payment
Not Approved — Letter to follow
Neighborhood will provide Authorization #, Dates of Service, Approved status, UM initials, and Notification Date

Definitions

Clinical pre-test probability — definition and form requirement

DefinitionEstimated likelihood of the diagnosis prior to testing.

Form requirementTest sensitivity must be greater than the clinical pre-test probability.

PurposeEnsures the requested genetic test is likely to change the member's clinical management.

How used on formClinical information section asks provider to demonstrate sensitivity > pre-test probability when justifying the test.

Related documentationProviders must state how positive and negative results will affect management (clinical justification).

CPT Code:	placeholder fields for CPT codes to be entered on the form
Diagnosis Code:	placeholder field for diagnosis code to be entered on the form

OpenPayer

Genetic Testing Prior Authorization Form — Coverage Criteria

Coverage Criteria

Covered Indications

Requested CPT / Diagnosis Codes

Provider Actions & Submission Requirements

Not Covered / Exclusions

Background

Definitions