Beginning on Oct. 1, 2022, Tufts Health Plan is implementing a genetic testing prior authorization program for Tufts Health Public Plans members, which will be managed by AIM Specialty Health® (AIM).

The program — similar to what has been in place for Harvard Pilgrim’s Commercial and Stride^SM (HMO) Medicare Advantage members since 2018 — will require ordering providers to obtain prior authorization through AIM for the following genetic/genomic or molecular diagnostic testing services, and AIM will employ their evidence-based clinical guidelines to conduct medical necessity review and utilization management:

• 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

As of Sept. 12, 2022, ordering providers may begin making prior authorization requests for genetic/genomic and molecular testing occurring on or after Oct. 1, 2022. The ordering clinician is responsible for obtaining prior authorization through AIM Specialty Health. Any genetic/genomic and molecular tests performed on or beyond the Oct. 1 program launch date will not be reimbursed if a prior authorization was not obtained. To ensure that these services are eligible for reimbursement, providers rendering the services should verify that the necessary prior authorization has been obtained prior to performing the test.

Submitting authorization requests
Ordering providers can request prior authorization from AIM online (the preferred method for quick, convenient service) via the AIM ProviderPortal, which is available 24 hours a day, 7 days a week. Alternatively, requests may be submitted by phone by calling AIM toll-free at 833-342-1255, Monday through Friday from 8 a.m. to 5 p.m. ET.

Provider education webinars coming soon
Tufts Health Plan and AIM will be hosting provider education webinars in September for those who want to learn more about prior authorization for genetic/genomic and molecular testing. We’ll be sharing more detailed information about these provider education webinars in next month’s issue of Provider Update.

Additional information
For more information, including the list of CPT codes applicable to the program, you can refer to the Prior Authorization Program for Genetic Testing section of the Tufts Health Plan Vendor Information page on our Provider website, as well as this provider FAQ document about the program. In addition, you can find prior authorization information, AIM’s genetic testing clinical guidelines, and other resources on the microsite AIM has developed specifically for Point32Health, which includes Tufts Health Plan and Harvard Pilgrim Health Care. 

Please refer to future issues of Provider Update for more information about this new genetic testing prior authorization program.