Medicare AdvantageMedicaidNovember 20, 2023
Transition to Carelon Medical Benefits Management, Inc. Genetic Testing Guidelines
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.
This communication applies to Medicaid and Medicare Advantage plans from Empire.
Effective April 1, 2024, Empire will transition to the following genetic testing guidelines for Carelon Medical Benefits Management, Inc. to perform medical necessity/clinical appropriateness reviews for requested genetic tests. Applicable CPT® codes lists are included in each guideline linked below:
- Carrier Screening in the Prenatal Setting and Preimplantation Genetic Testing
- Cell-free DNA Testing for the Management of Cancer
- Chromosomal Microarray Analysis
- Genetic Testing for Inherited Conditions
- Hereditary Cancer Testing
- Pharmacogenomic Testing
- Polygenic Risk Scores
- Prenatal Testing using cell-free DNA
- Somatic Tumor Testing
- Whole Exome Sequencing and Whole Genome Sequencing
Prior authorization requirements remain the same. The requested services received on or after April 1, 2024, will be reviewed with the new Clinical Criteria.
As a reminder, ordering and servicing providers may submit prior authorization requests directly to the ProviderPortalSM for Carelon Medical Benefits Management directly at providerportal.com. Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
For questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.
Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.
Medicaid products offered by Empire BlueCross BlueShield HealthPlus, trade name of HealthPlus HP, LLC. Services provided by Empire HealthChoice HMO, Inc., Empire HealthChoice Assurance, Inc., or Empire BlueCross BlueShield Retiree Solutions. Empire BlueCross BlueShield Retiree Solutions is the trade name of Anthem Insurance Companies, Inc. lndependent licensees of the Blue Cross Blue Shield Association, an association of independent Blue Cross Blue Shield plans.
NYBCBS-CDCR-041221-23-CPN40797
PUBLICATIONS: December 2023 Provider Newsletter
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