WellFirst Health updates medical policies for Genetic Testing biannually on an ongoing basis. As genetic testing has increasingly become the standard of care, WellFirst Health is committed to the access and quality of these services for our members.
Our current genetic testing policies were developed by our contracted vendor, Concert Genetics, an industry leader in genetic testing technology assessment and policy development. Search Genetic Testing policies in our Document Library.
Here are a few things to consider
Although prior authorization is no longer required for genetic testing as of 7/1/2023, when utilizing providers allowed under the member's plan, claims will still need to be coded correctly and services still need to be medically necessary based on coverage criteria. Claims may be denied if this information is not provided or accurate.
Not all genetic tests are considered a covered benefit under the member's plan. Contact the Customer Care Center to confirm the recommended testing is a covered benefit of the member's plan.
- General Approach to Genetic Testing Medical Policy MP9610 (PDF), describes the general approach for any genetic testing not specifically addressed in another policy. It also serves as the general policy for genetic testing and will provide links to specific genetic tests.
- Genetic tests must meet applicable evidenced based guidelines and be medically necessary.
- Genetic counseling and medical necessity requirements may be test specific, as identified within each medical policy.
- Medical necessity criteria will be applied to Commercial HMO, POS, PPO, and ASO members. WellFirst Health Medicare Advantage does not have genetic testing authorization requirements.
- ASO members are excluded from any Genetic Counseling requirements.
- For laboratories only — Every genetic test is assigned a genetic testing unit (GTU), a unique alphanumeric identifier for payers who utilize Concert Genetic services. This unique GTU may be found on the Concert Genetic Platform. Every genetic test has been assigned a GTU. Log in at concertgenetics.com to find the GTU for your requested genetic test.
See our full list of genetic testing policies.
Genetic counseling requirement
Certain tests require pre-test and post- test genetic counseling. Prior authorization is not required for referrals to a genetic counselor.