Tufts Health Plan vendor information

The Tufts Health Public Plans Genetic Testing Authorization Program will be managed by Carelon Medical Benefits Management (formerly AIM Specialty Health), beginning Oct. 1, 2022. This authorization program applies for members of Tufts Health Direct, Tufts Health Together, Tufts Health One Care, and Tufts Health RITogether.

Providers will be required to obtain prior authorization through Carelon for genetic/genomic or molecular tests, and Carelon will employ their evidence-based clinical guidelines to conduct medical necessity review and utilization management. Prior authorization is required for the following services:

• Reproductive Carrier Screening
• Prenatal Testing
• Preimplantation Genetic Testing (PGT)
• Rare Disease Testing
• Whole Exome/Genome Sequencing
• Hereditary Cancer Testing
• Tumor Markers
• Hereditary Cardiac Testing
• Neurogenetic and Neuromuscular Testing
• Pharmacogenomics and Thrombophilia Testing
• Susceptibility Testing for Common Diseases

Additionally, preauthorization through Carelon is required for the CPT codes 89290 and 89291 associated with preimplantation genetic diagnosis.

Requesting authorization

The ordering clinician is responsible for starting the AIM prior authorization process before the sample collection date. Please submit you authorization request in one of the following ways:

• Online (suggested method) via Carelon’s portal at www.providerportal.com
  • Fast, convenient service. The Carelon ProviderPortal is available 24 hours/day, 7 days/week.
  • Start a new order, update an existing order, and retrieve your order summary
  • Register at www.providerportal.com. If you need any help using the Carelon ProviderPortal, call Carelon ProviderPortal support at 800-252-2021.
• By phone:
  • Call Carelon Specialty Health toll-free at: 833-342-1255
  • Hours: Monday – Friday 8 a.m. – 5 p.m. (ET)

The servicing lab should confirm that the ordering clinician has completed the prior authorization process before provider services by requiring evidence of an approved Carelon transaction number. If a servicing lab conducts one of the genetic tests listed above for which authorization was not completed, the procedure will not be reimbursed and the member cannot be billed. 

Additional information

You can find more information about the program in this provider FAQ document, as well as the microsite Carelon has developed specifically for Point32Health — which includes Tufts Health Plan and Harvard Pilgrim Health Care. Refer to this table for a list of CPT codes that Carelon manages on behalf of Tufts Health Public Plans.

For other Tufts Health Plan Products

For Tufts Health Plan commercial products, please refer to the following Medical Necessity Guidelines and submit authorization requests for genetic testing directly to Tufts Health Plan:

• Genetic and Molecular Diagnostic Testing
• Preimplantation Genetic Diagnosis (PGD)
• Genetic Testing:
  • BRCA-Related Breast and/or Ovarian Cancer Syndrome
  • Cell-Free DNA Testing for Fetal Trisomy
  • Gene Expression for Cancer of Unknown Primary (CUP)
  • Prenatal Diagnosis, Carrier Screening (formerly Prenatal, Preconception)

Prior authorization is not required for genetic testing for members of Tufts Health Plan Senior Care Options, Tufts Medicare Preferred, Tufts Medicare Complement, and Tufts Medicare Preferred Supplement – with the exception of the FoundationOne CDx and ThyroSeq tests, which require prior authorization for Tufts Health Plan Senior Care Options and Tufts Medicare Preferred (refer to their respective Prior Authorization lists here and here.)

About Carelon

Carelon is an NCQA certified and URAC accredited specialty benefits management company. Carelon promotes appropriate use of specialty care services through the application of widely accepted clinical guidelines delivered via an innovative platform of technologies and services.

Evolent (formerly National Imaging Associates) reviews medical necessity and provides prior authorizations on behalf of Tufts Health Plan for Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RI Together, Tufts Health One Care for select outpatient and inpatient services in the following categories: Cardiac, Joint Surgery, Outpatient High-Tech Imaging, and Spinal Conditions Management. For details for Tufts Health Public Plans members, visit this Evolent page. For other Tufts Health Plan products, visit this Evolent page.

Providers may be contacted by Evolent by phone, fax and/or letter as part of the prior authorization process. To obtain/verify authorizations or access medical necessity guidelines, log in to RadMD or call 866-642-9703 (Tufts Health Plan products) or 800-207-4209 (Tufts Health Public Plans products).