Laboratory Management Program

Highmark contracts with eviCore to manage molecular and genomic testing within a new Laboratory Management Program. The Laboratory Management Program utilizes evidence-based policies, developed with trained genetic experts, to ensure that the genetic lab services provided to Highmark's members support clinically appropriate care and are medically necessary, in accordance with their benefit policy.

Effective with dates of service on or after August 1, 2016, Highmark requires prior authorization for several molecular and genomic tests when performed in an outpatient setting for fully-insured Commercial, ACA and Medicare Advantage members. These tests include:

• Hereditary Cancer Screening
• Carrier Screening Tests
• Tumor Marker/Molecular Profiling
• Hereditary Cardiac Disorders
• Cardiovascular Disease And Thrombosis Risk Variant Testing
• Pharmacogenomic Testing
• Neurologic Disorders
• Mitochondrial Disease Testing
• Intellectual Disability/Developmental Disorders

Effective Aug. 1, 2016, claims associated with molecular and genomic procedure codes will be reviewed for accuracy and medical necessity prior to payment, based on eviCore's policies. This review is not limited to only those codes for which authorization is required. Any services performed without a prior authorization may be denied, and providers may not seek reimbursement from members.

Learn More About the Laboratory Management Program

eviCore has a dedicated webpage for Highmark providers to conveniently access the most up-to-date announcements, clinical guidelines, and procedure code lists for prior authorization and claims review.  We encourage you to visit their site to ensure that you have the most current information.

Reference Materials

• Lab Management Program Admin Guide (Revised January 2018)
     - This guide includes a summary of all components of the Laboratory Management Program.
• eviCore Prior Authorization Quick Reference Guide

Educational Materials/Communications

• Laboratory Management Program Orientation Presentation
• eviCore Lab Management Program FAQs
• Lab Management Program Special Bulletin - April 29, 2016
• Lab Management Program Today’s Message Update - June 9, 2016
• Lab Management Program Prior Authorization Date Change - June 27, 2016
• Laboratory Management Program Changes to Occur on June 30, 2017, and July 31, 2017 Special eBulletin - May 26, 2017

DISCLAIMER:

eviCore is a is a separate company that works with Highmark to administer the Lab Management Program. eviCore does not provide Blue Cross and/or Blue Shield products or services. eviCore is solely responsible for the products and services described here.