Molecular Diagnostic / Genetic Testing

Preauthorization and Notification

Molecular diagnostic/genetic testing (MD / GT) was previously added to Humana’s Commercial Preauthorization and Notification List. These services will now be administered by DNA Direct, a provider of genetic testing management services. Please note that precertification, preadmission, preauthorization and notification requirements all refer to the same process of preauthorization.

Effective July 10, 2009, Humana will implement a MD / GT preauthorization program. The MD / GT preauthorization program will affect 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; Medicare; Medicaid; CarePlus and Cariten members are excluded from this program.

Submitting Preauthorization Requests

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

Humana.com

Physicians may log into 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 Web site at DNA Direct. 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 also have access to information about the indication and use of the MD / GT they are ordering.

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. DNA Direct 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.

Availity.com (available in Availity markets only)

To access Humana's Genetic Guidance Center and complete a preauthorization request, visit DNA Direct.

Physicians will be asked to provide information and / or answer questions about the patient's condition and past medical / family history.

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 members’ personal health information, physicians requesting preauthorizations through the IVR phone line and / or DNA Direct’s Web site 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.

Physicians who submit preauthorization requests via IVR have the option to create a username and password.

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.

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

Questions

Questions about this program may be directed to Humana:

By Phone:

1-800-523-0023
Monday - Friday 8 a.m. - 6 p.m. local time