CurrentSelectHealthPolicy N/A

Reimbursement Policy for Genetic/Molecular Test Coding

This document governs coding and billing for genetic and molecular laboratory tests billed to SelectHealth and requires providers to bill according to Concert's coding recommendations; it affects laboratories (performing and billing labs) serving SelectHealth members.

Policy Summary

PayerSelectHealth

PolicyReimbursement Policy for Genetic/Molecular Test Coding

Policy CodePolicy N/A

Change TypeOperational requirement; vendor engagement

Effective DateNov 1, 2025

Next Review DateN/A

Key ActionAfter 2025-11-01, providers billing for genetic and molecular testing must bill according to the coding recommendation in the Concert portal.

SourceLink

POLICY UPDATE CHANGES

Select Health will require that all providers billing for genetic and molecular testing services bill according to the coding recommendation in the Concert portal after the effective date.

Concert has been engaged by SelectHealth to provide data and technology to support relationships with genetic testing laboratories and improve linkages between tests and billing codes.

11/1/25policy effective date

1required external vendor

4code sections cited

2onboarding days

Coverage and Operational Criteria

Coverage and operational criteria for genetic/molecular test coding

SelectHealth requires that claims for genetic and molecular tests be coded according to Concert recommendations; applicable code sections are listed below.

Providers must bill genetic and molecular testing services according to the coding recommendation in the Concert portal effective 11/1/25.

This requirement applies to services billed from the following CPT/IHCPCS sections: Molecular Pathology; Genomic Sequencing Procedures and Other Molecular Multianalyte Assays; Multianalyte Assays with Algorithmic Analyses; and Proprietary Laboratory Analyses (PLA) codes.

Performing laboratories must register with Concert to validate test catalog data and receive coding recommendations.

Hospital in-house laboratories should register with Concert to determine coding recommendations; hospital labs billing directly for send-out genetic testing should bill in accordance with the performing laboratory's Concert coding recommendation.

Genetic / Molecular Test Coding

Genetic/Molecular test code sectionsmixed

Codes billed from Molecular Pathology; Genomic Sequencing Procedures and Other Molecular Multianalyte Assays; Multianalyte Assays with Algorithmic Analyses; and Proprietary Laboratory Analyses (PLA) Codes

Code update responsiveness

Update cadenceConcert updates recommended codes as soon as test content changes are updated in the Concert database; CPT code set updates are incorporated when they become effective per the AMA.

Trigger for updatesInclusion or removal of genes or other test content changes that alter coding (e.g., qualifying a test for a panel code).

Source of CPT changesCPT code set changes are adopted into Concert recommendations when the AMA makes them effective.

Operational effectLabs and billers should expect recommended codes to change promptly after Concert database updates and after AMA CPT effective dates.

Provider Billing and Registration Requirements

Billing Rule

Bill using Concert coding recommendations after 11/1/25

After 11/1/2025, Select Health requires that all providers billing for genetic and molecular testing services bill using the coding recommendation published in the Concert portal.

Prior Authorization

Only the performing laboratory is required to register with Concert to validate test catalog data and receive coding recommendations; however, referring labs that bill according to Concert recommendations may create an account to view recommendations. Hospital labs billing for send-out tests should bill according to the performing lab's Concert recommendation, and hospital in-house labs should register with Concert.

Performing laboratories: must register at the Concert site and will receive onboarding materials (welcome packet and platform invitation) within two business days.

Key Definitions

Concert Coding Engine

DefinitionConcert Coding Engine: a method to translate a genetic test into a single code or code combination using defined guiding principles, finite data elements, and repeatable output.

PurposeStandardizes the coding process for genetic testing so stakeholders arrive at a single way to code each marketed test.

How it operatesOperates according to concise guiding principles and relies on finite data elements to generate repeatable coding recommendations.

Quality profile

DefinitionQuality profile: a customized quality metrics questionnaire that leverages industry-standard quality programs and is tailored to genetic testing while minimizing laboratory burden.

Goal