Proactively manage genetic test spend
As genetic testing becomes the standard of care for many health conditions, the number of tests available in the market has soared. With over 10 new tests added daily, many don’t meet the criteria for clinical or analytical utility. And with fewer than 500 CPT® billing codes to describe the nearly 130,000 genetic tests available in the market, reimbursement can be complex. 1,2
Optum® Genomics Payment Manager helps health plans proactively manage genetic testing spend by correctly identifying tests, automatically mapping billing codes to genetic tests and analyzing claims for inappropriate billing behaviors.
Unique test identification
Through our exclusive partnership with Palmetto GBA, who administers the MolDX program leveraged by Medicare Fee-For-Service (FFS), we utilize the reliable DEX® Diagnostics Exchange. This platform assigns unique DEX Z-Code® identifiers to each test, aiding in the cataloging and management of the tests. By leveraging these familiar processes, we help validate that only clinically relevant and appropriate tests are covered, aligning with health plan policies.
Z-Codes drill down beyond the CPT® code and identify a discrete genetic test on a claim, allowing for automated correct coding edits, Medicare-sourced coverage determinations and pricing recommendations.
Improve regulatory compliance
DEX Z-Codes® are an extension of the Medicare FFS MOlDx program, which has been used for over a decade by Medicare Administrative Contractors (MACs) to improve payment accuracy on genetic testing claims.
Biomarker compliance laws vary by state. Some states require health plans to cover biomarker testing similar to Medicare Fee-For-Service (FFS). Genomics Payment Manager can help health plans improve patient access to necessary tests.
Key benefits
Support biomarker compliance and accurate reimbursement for genetic testing.
Greater policy enforcement and payment specificity
We create a one-to-one relationship between the Z-code, CPT code, test and lab, allowing for automated policy enforcement and payment decisions at the discrete test level.
Commitment to test quality
The DEX® Diagnostics Exchange performs clinically stringent technical assessments on all lab-submitted tests to help validate quality for members and physicians.
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Sources
1. Halbisen AL, Lu CY. Trends in Availability of Genetic Tests in the United States, 2012-2022. J Pers Med. 2023 Apr 6;13(4):638. doi: 10.3390/jpm13040638. PMID: 37109024; PMCID: PMC10142561.
2. Laboratory Hub. Laboratory Hub. Understanding CPT and ICD Codes in Laboratory Billing. Oct. 7, 2023.