Genetic Testing claim edits

For professional claims submitted on a CMS-1500 form processed on or after April 26, 2023, Anthem will enhance our editing systems to automate edits and simplify remittance messaging. These edit enhancements are supported by correct coding guidelines, as documented in industry sources such as Correct Procedural Terminology (CPT^®) guidelines and Centers for Medicare & Medicaid Services (CMS). Additionally, these edit enhancements will promote faster claim processing and reduce follow-up audits and/or record requests for claims that are not consistent with correct coding guidelines. As a result of these edit enhancements, there will be greater attention on identifying inappropriate billing of genetic testing services.

Below are examples of claim edits focused on identifying inappropriate billing of genetic testing services that will be automated:

• Multianalyte Assays with Algorithmic Analyses (MAAA) — CPT 81507: This edit will deny laboratory provider claims submitted with the proprietary laboratory analysis code for the associated proprietary Harmony prenatal test when the laboratory provider is not an affiliated proprietary laboratory.
• Panel testing: This edit will deny laboratory provider claims submitted with codes for individual components of a panel test (for example, tumors, inherited conditions, and hematologic malignancy) when a single panel code exists.

Providers who believe their medical record documentation supports services billed should follow the claims payment dispute process (including submission of all supporting documentation with the dispute) as outlined in the provider manual.

If you have questions on this program, contact your Provider Relationship Account Manager.