Prior Authorization

As you are aware, many third-party payers require Prior Authorization for patients in need of important genetic and molecular laboratory testing. Without a Prior Authorization, your patient’s claim for reimbursement of the test will be rejected and they may receive a significant bill from CTGT-HNL Lab Medicine for this testing.

CTGT-HNL Lab Medicine will partner with you in obtaining Prior Authorization. While many insurers require that the health care professional ordering the test apply for Prior Authorization, CTGT-HNL Lab Medicine will work to submit the request on behalf of you and your patient (in most instances) so that testing can be authorized, performed and reimbursed without significant delay or co-payment required.

The Prior Authorization process requires that the insurance company is provided necessary clinical information to support the clinical need for the test. CTGT-HNL Lab Medicine has provided the attached form to easily collect the relevant information that we may convey to the insurance company. In some instances, this form may not answer all the questions that the insurance company requires. For this reason, our staff may contact your office for additional information if the insurance company requires it.

CTGT-HNL Lab Medicine also requires that all requests for genetic and molecular laboratory testing are accompanied by the attached Clinical History Form AND a recent pathology report, relevant clinic encounter notes or medical genetics consultation. CTGT-HNL Lab Medicine will process the patient’s specimen to ensure stability of the specimen but may HOLD the specimen and NOT complete the test until all information for the Prior Authorization is received.

Download the Prior Authorization Information packet

Helpful Tips

  • Prior Authorization for genetic and molecular laboratory testing is required by many, but not all, third party payers.

  • When CTGT-HNL Lab Medicine can bill the patient’s insurance directly for genetic and molecular laboratory testing, CTGT-HNL Lab Medicine will submit Prior Authorization requests.

  • In cases where CTGT-HNL Lab Medicine will be submitting the Prior Authorization request and billing the patient’s insurance, CTGT-HNL Lab Medicine requires completion of a Clinical History Form in addition to a test requisition.

  • CTGT-HNL Lab Medicine will process and HOLD all specimens referred for genetic and molecular laboratory testing until ALL necessary clinical information for Prior Authorization submissions are received.

  • CTGT-HNL Lab Medicine reserves the right to bill the client or your patient for genetic and molecular laboratory testing in which Prior Authorization information is not received, or the third-party payer denies the request.

  • If Prior Authorization is denied, the ordering facility will be notified and given the option to cancel the test. If the test is canceled, a DNA extraction fee may apply.

  • Prior Authorization is not a guarantee of payment.

Frequently Asked Questions

Yes! If you complete the Clinical History Form, we can attempt the process for you.   (Prior Authorization)

Please contact CTGT via 484-244-2900 or   (Prior Authorization). Our experts would be happy to assist you with all questions regarding Prior Authorization.

Clinical coverage reviews will be based on third party clinical policy requirements for coverage. These policies include clinical criteria and information about coverage eligibility for related services. If a request needs review or requires additional clinical information, we will contact the ordering health care professional.

Prior Authorization, also known as a pre-authorization or pre-certification, is a clause in the health insurance policy that says the patient must get permission from their health insurance company before they receive certain health care services which includes specialized laboratory testing. This process was developed to help ordering health care professionals, laboratories and their patients receive a quicker coverage determination by giving them information:

  • If a member’s benefit plan requires prior authorization.

  • When additional clinical information is required to make a coverage decision.

  • Whether the request meets third party’s clinical and coverage policy criteria.

Specialized laboratory testing that requires Prior Authorization can usually be found on the health plan’s website or by calling the health plan directly. Many genetic and molecular tests require Prior Authorization for outpatient services.

The health care professional who is ordering the testing is responsible for obtaining Prior Authorization for the specialized laboratory test. If the health care professional’s office does not obtain the necessary Prior Authorization before testing, the patient will be responsible for payment, which can range in cost from just under one hundred dollars to thousands of dollars based on the test ordered.

The American Medical Association (AMA) Current Procedural Terminology (CPT) codes published by HNL Lab Medicine are guidelines and are intended for informational purposes only. CPT coding is the exclusive responsibility of the billing entity. HNL Lab Medicine strongly recommends confirmation of CPT codes with third-party payors and/or the AMA. We assume no responsibility for billing errors due to reliance upon CPT codes provided by HNL Lab Medicine.

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