Prior authorization is a process used by many insurance companies to determine if a procedure, service, or medication will be covered before services are rendered. Most insurance companies require prior authorization for certain genetic and molecular laboratory testing. Additionally, insurance companies have specific medical criteria for genetic testing, even if prior authorization is not required.
Where do I start?
You may have received a card or other document as proof of health insurance. All cards vary, but should have the same type of information as the example shown below.
Contact your insurance company’s Member Services or Customer Service department for help in determining coverage for specific services as well as your financial responsibility. Some important questions to ask:
- Are the tests mentioned a covered benefit under my policy?
- What is my out-of-pocket financial responsibility for the tests, including deductible or copay?
- What medical criteria must be met?
- Does this test require prior authorization?
How is prior authorization obtained?
The Member Services or Customer Service department at your insurance company should be able to provide you with specific requirements for your policy. Upon receipt of your lab orders and sample, CPL will contact your insurance company to verify eligibility and benefits along with prior authorization requirements. CPL will coordinate with your physician for submission of the necessary documentation to your insurance company to request a prior authorization review. After the prior authorization case is approved by your insurance company, testing can begin.
What do I do if the prior authorization for my test is denied or the test is not a covered benefit under my policy?
Even if prior authorization for your test is denied or your insurance policy excludes the service from benefits, you may still seek testing but you will be held responsible for the cost of the test(s). CPL offers a patient savings program or financial assistance for patients who meet criteria. Please reach out to a CPL Care Specialist at 833.583.2028 for more information on these programs or assistance with the prior authorization process. We are available Monday-Friday, 8AM to 5PM central time, closed Noon to 1PM for lunch.
Important Note: Prior authorization approvals are coverage determinations and do not eliminate the patient’s financial responsibility, if applicable.