Molecular Diagnostic / Genetic Testing

Humana's Genetic Guidance Center

The Genetic Guidance Program is a utilization management initiative designed to share information with physicians and members about the use and appropriateness of MD/GTs. DNA Direct, a provider of genetic testing management services, facilitates medically necessary MD/GT at participating laboratories.

Board-certified genetic counselors are available to discuss genetic testing services, and preauthorizations follow Humana's clinical policies.

Preauthorization and Notification

The MD/GT preauthorization program currently affects Humana commercial fully insured and select administrative services only (ASO) members. Please note: Commercial fully insured HMO risk groups in Florida, Illinois and Texas; Puerto Rico; Medicaid; CarePlus and HumanaOne^® members are not affected.

Starting January 22, 2011, the MD/GT preauthorization program will affect Humana MA HMO, MA PPO and most ASO members. Please note: MA Private Fee-for-Service (PFFS) members and MA members in HMO risk groups in Florida, Illinois, Nevada, Arizona and California are not affected.

Submitting Preauthorization Requests

Humana requires that any MD/GT ordered for a Humana commercially insured and MA patient be administered through our Genetic Guidance Center at DNA Direct. Physicians have several options when submitting their preauthorization requests:

Genetic Guidance Center website

Physicians may log in to Humana's Genetic Guidance Center website at DNA Direct to initiate preauthorization. Physicians will be asked to complete a questionnaire or a form requesting more information about the patient's condition and past medical/family history. Physicians will receive a response to their request at the end of the process. Physicians will also have access to online educational information about the indication and use of the MD/GT they are ordering.

Humana.com

Physicians may log in to the secure provider area of Humana.com (registration required) to initiate a preauthorization request. When requesting preauthorization for an MD/GT, physicians will be directly linked to Humana's Genetic Guidance Center website at DNA Direct. Once there, physicians will be prompted to complete a questionnaire appropriate for the test they are ordering.

Genetic Guidance Center Phone Line (1-877-506-5193)

Physicians may contact a DNA Direct representative via phone by calling 1-877-506-5193. Representatives are available from 8 a.m. to 8 p.m. Eastern time, Monday through Friday.

A board-certified genetic counselor will ask the physician questions about the patient's condition and past medical/family history. Genetic counselors will also be able to answer questions related to the test(s) the physician is ordering and applicable Humana clinical policies.

Interactive Voice Response (IVR)

Physicians may call Humana's interactive voice response (IVR) line to initiate a preauthorization request at 1-800-523-0023. When requesting preauthorization for an MD/GT, physicians will be transferred to Humana's Genetic Guidance Center at DNA Direct where they will speak to a DNA Direct representative who will facilitate the preauthorization process.

Information Needed When Requesting Preauthorization

The physician should have relevant clinical information available in the patient's chart when requesting the preauthorization, including the following:

• Member name and Humana member ID number
• Ordering physician name, provider ID or tax ID
• Telephone and fax numbers
• Patient diagnosis or clinical indication (ICD-9 code)
• Test being ordered (CPT code or test name)
• Indication/reason for test
• Patient signs, symptoms and duration
• Prior related diagnostic and/or genetic tests and their results
• Laboratory studies and results
• Family medical/genetic history
• Patient medications and duration (if related)
• Prior treatments or other clinical findings (when relevant)
• Servicing provider name (i.e., lab or facility that is going to perform the test)
• How the test results will be utilized in the patient's care

Privacy Policy

To protect the privacy and confidentiality of our member's personal health information, physicians requesting preauthorizations through the IVR phone line and/or DNA Direct's website will be asked to register with DNA Direct. Physicians will create a username and password to submit a preauthorization request via the DNA Direct website.

Exclusions to Preauthorization

While most genetic tests and molecular diagnostics require prior authorization, there are some exclusions. At this time, the following categories are excluded:

• Routine prenatal screening
• Routine inpatient newborn screenings
• Human leukocyte antigen (HLA) testing for transplant
• Chromosomal analysis for leukemia and lymphoma
• Infectious disease testing considered to be standard of care

For all other tests, the provider should contact DNA Direct for preauthorization.

Tests and Disease States Included in the Humana Genetic Guidance Program

Click below to find a list of genetic tests and disease states that are included in the Humana Genetic Guidance Program.

Humana Genetic Guidance

A list of genetic tests and disease states that are included on the HumanaGenetic Guidance Program.

(313 KB) Download PDF

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Clinical Policies

To learn more about Humana's Clinical Policies for Molecular Diagnostic/Genetic Tests, search for the term "genetic" using the Medical Coverage Policies Tool