Billing Information for Genetic/Genomic Testing
BRCA1 and BRCA2 Screening and the High-Risk Hereditary Breast Cancer Panel
Inform Diagnostics offers genetic testing as part of our breast health
services. This page contains billing and coverage information for the
BRCA1 and BRCA2 screening and High-Risk Hereditary Breast Cancer Panel.
Note that coverage of genetic/genomic testing by insurance providers varies
greatly depending on payor policy, patient plan, patient medical condition,
and other factors. Prior authorization is required and will be performed
by Inform Diagnostics before testing is initiated. Please see the sections
below for Inform Diagnostics’ Genomic Testing Policy and Billing
Medicare pays for genetic testing when the test is considered medically
necessary and the criteria in applicable Local Coverage Determination
policies are met. Medicare claims for services performed at Baylor Genetics
are processed by the Medicare Administrative Contractor (MAC) for the
state of Texas, Noridian Solutions, LLC.
Providers should consult the
MCR TX Local Coverage Determination (LCD) for BRCA1 and BRCA2 to determine if their patient meets criteria for genetic testing before
For Medicare patients who do not meet medical criteria, the patient must
complete an Advanced Beneficiary Notice of Non-coverage (ABN form) and this form must be submitted to Inform Diagnostics before testing
will begin. Because Medicare will likely not cover test costs for patients
who do not meet Medicare criteria, test costs will be billed to the patient.
A summary of instructions for Medicare patients is included on the ABN.
Aetna — Aetna requires that patients meet coverage criteria to be eligible
for BRCA1 and BRCA2 Screening and the High-Risk Hereditary Breast Cancer
Panel and requires that the tests be pre-authorized. For prior authorization,
Aetna requires the
Aetna Prior Authorization Request form to be completed. Inform Diagnostics will facilitate the authorization
request once the specimen, completed requisition, insurance information
and clinical notes are received. If Aetna denies testing, the provider
will be notified.
United Healthcare and Cigna — United Healthcare and Cigna require that patients undergo genetic
counseling to determine medical criteria eligibility for BRCA1 and BRCA2
Screening and the High-Risk Hereditary Breast Cancer Panel. Following
the completion of genetic counseling, prior-authorization is required.
Inform Diagnostics will facilitate counseling with an independent genetic
counselor and prior-authorization upon receipt of specimen, completed
requisition and insurance information. If United Healthcare or Cigna denies
testing, the healthcare provider will be notified.
Genomic Testing Policy
To protect patients, Inform Diagnostics follows the policy below when billing
insurance for genetic testing:
- Testing will be on hold until Inform Diagnostics completes the verification
of benefits or prior-authorization with insurance provider. This process
averages from 2–15 days.
- If testing is covered by insurance provider, Inform Diagnostics will proceed
if the patient responsibility is estimated to be less than $100. The patient
will be financially responsible for any amounts not covered, such as a
co-pay or deductible.
- If the patient responsibility is estimated to exceed $100, Inform Diagnostics
will contact the patient to determine how to proceed and if testing should
be performed or canceled.
If a patient has questions about a bill from Inform Diagnostics, please
call us at 888.344.1160.
The Inform Diagnostics billing team will work diligently to create a payment
option that will work for patients. Our billing team can offer interest-free
monthly payment plans if a patient's insurance, deductible, or uncovered
services pose a financial burden. The patient should call Inform Diagnostics
directly for assistance at 888.344.1160.
Patients may receive an Explanation of Benefits (EOB) from their insurance
company for services provided by Inform Diagnostics or one of its affiliate labs.
Please remember that an EOB is not a bill. The patient should only pay Inform Diagnostics if they receive an invoice
from us. Sometimes our lab may be out of network. Where permitted by law,
we will adjust the patient responsibility to an
in-network level of benefit.
For any questions or concerns about an invoice, please contact our billing
team as soon as possible. The Inform Diagnostics team will be happy to
answer any questions about the patient pathology payment responsibility.
We are committed to working with you.
For questions and additional information, see our
Billing Information page.