CurrentWellCarePolicy CG.PP.551

Genetic and Molecular Testing Services

Defines billing, coding, and reimbursement requirements for genetic and molecular testing for WellCare-affiliated health plans and laboratories, including use of Concert Coding Engine and Genetic Testing Unit (GTU) identifiers; applies to participating and certain non‑participating providers rendering covered services.

Policy Summary

PayerWellCare

PolicyGenetic and Molecular Testing Services

Policy CodePolicy CG.PP.551

Change TypeOperational revisions and additions

Effective Date

Next Review DateFeb 26, 2025

Key ActionAll providers requesting authorization for genetic and molecular testing must add the appropriate Concert Genetics GTU descriptor to authorization requests and register on the Concert portal.

SourceLink

POLICY UPDATE CHANGES

Updated vendor name to "Concert" and aligned Application section to list applicable code sections (Pathology and Laboratory Procedures 80000 codes; PLA U codes; MAAA M codes; Level II HCPCS).

Added Table 2 specifying GTU claim field location and required GTU format for claims.

Clarified reimbursement requirements to bill for the test performed as delivered on the test result and to include ordering and rendering provider information on claims.

Table 1CPT code ranges subject to GTU

GTU requiredGTU requirement

One unitUnit limit for 81479/81599

Policy Summary

PayerWellCare

PolicyGenetic and Molecular Testing Services

Policy CodePolicy CG.PP.551

Change TypeOperational revisions and additions

Effective Date

Next Review DateFeb 26, 2025

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.

Billing and Reimbursement Requirements

Billing and coding criteria

Providers and laboratories must follow the billing, coding, and claim-submission requirements below for genetic and molecular testing claims to be considered for payment:

Include ordering and rendering provider information, the date and place of service, and appropriate, specific ICD diagnosis codes on all claim transactions. Header (3-digit) ICD codes may lack necessary specificity and can be denied for insufficient specificity.

Bill for the test performed as indicated on the test requisition and delivered on the test result.

Procedure codes must be determined by the attributes of the testing performed (not by clinical indication). If a PLA or MAAA code is assigned for the test, that PLA/MAAA code must be used. If a panel code is appropriate it must be used; if not, a limited number of individual components may be billed per policy guidance.

Laboratories must register on the Concert portal, complete the Concert quality profile, and bill according to Concert Coding Engine standards. All providers requesting authorization must add the appropriate Concert GTU descriptor to authorization requests.

Insert the exact Concert GTU (or the GTU preceded by 'GTU-') in the required electronic or paper claim field/segment for all molecular/genetic testing codes listed in Table 1 per Table 2 claim-field mapping (examples: 837P Loop 2400 SV101-7; 837I Loop 2400 SV202-7; CMS-1500 item 19; CMS-1450 item 80).

Units of service billed must comply with NCCI PTP and MUE edits: do not exceed the MUE for a code and follow applicable PTP edit rules and modifier guidance. Per policy, report only one unit of service for certain genomic sequencing procedures and only one unit for the non-specific CPT codes 81479 and 81599 per test.

Use appropriate modifiers per NCCI guidance: Modifier 52 may be used when interpretation occurs without wet lab procedures; Modifier 59 may be used only if no other appropriate modifier describes the service; other modifiers may be used when billing multiple service units is appropriate (e.g., repeat testing, multiple specimens).

Missing required claim elements (including GTU where required) or failure to follow these coding and billing rules may result in denial of payment.

Codes Subject to GTU and Unit Limits

Molecular/genetic testing codes subject to GTU - Tier 1CPTCovered

81105-81383

Tier 1 CPT Codes

Molecular/genetic testing codes subject to GTU - Tier 2CPTCovered

81400-81408, 81479

Tier 2 CPT Codes

Molecular/genetic testing codes subject to GTU - Genomic Sequencing ProceduresCPTCovered

81410-81471

Genomic Sequencing Procedures and other molecular multianalyte assays

Molecular/genetic testing codes subject to GTU - MAAACPTCovered

81490-81599

Multianalyte Assays with Algorithmic Analyses (MAAA)

Molecular/genetic testing codes subject to GTU - PLACPTCovered

PLA (U codes)

Proprietary Laboratory Analyses

Molecular/genetic testing codes subject to GTU - HCPCSHCPCSCovered

HCPCS Level II

HCPCS codes for genetic/molecular testing

Units of service limits — NCCI MUE guidance and single-unit restrictions for specific codes

NCCI/MUE complianceUnits billed must not exceed NCCI Procedure-to-Procedure (PTP) edits and Medically Unlikely Edit (MUE) maximum units of service; follow NCCI Manual definitions for MUEs.

Single-unit sequencing proceduresPer NCCI Manual, Chapter 10, Section F-8, when one laboratory procedure evaluates multiple genes using a next-generation sequencing procedure, report only one unit of service of one genomic sequencing procedure.

Non-specific CPT codes limitOnly one unit of the non-specific procedure codes CPT 81479 and 81599 may be billed per test.

Consolidated multianalyte testingIf a test evaluates multiple analytes using a procedure that consolidates part of the testing process (e.g., tandem mass spectrometry), report only one unit of an appropriate level II HCPCS, CPT, or PLA code.

Use of modifiers for multiple unitsModifier guidance: use appropriate modifiers per NCCI when billing multiple service units (e.g., repeat testing, multiple specimens); Modifier 52 may be used when wet lab procedures were not performed; Modifier 59 only if no other appropriate modifier describes the service.

Registration, Authorization, and GTU Requirements

Prior Authorization

All providers requesting authorization for genetic and molecular testing must register on the Concert portal and include the appropriate Concert Genetics GTU descriptor on authorization requests and claims.

Register on the Concert website (https://app.concertgenetics.com) to access Concert GTUs and bill according to the Concert coding engine standards.
Complete the brief quality profile on the Concert portal.
Include the appropriate Concert Genetics GTU descriptor on all authorization requests (and on claims per Table 2 requirements).

Key Terms

GTU — Genetic Testing Unit (GTU)

DefinitionGenetic Testing Unit (GTU) — a unique Concert-assigned identifier required on claims for all molecular/genetic testing codes listed in Table 1; it is provided via the Concert portal.

Claim placement requirementInsert the exact Concert GTU or the GTU preceded by 'GTU-' (e.g., GTU-6V98G) in the specified electronic or paper claim fields per Table 2.

Applicable codesRequired for all molecular/genetic testing codes noted in Table 1 (see policy Table 1 ranges).

Registration dependencyProviders must register on the Concert website to access GTUs and to bill according to Concert standards.

Concert Coding Engine — definition and use

PurposeConcert Coding Engine — a Concert-developed method that translates a genetic test into a single code or a standardized code combination to unify how tests are coded.