Genetic testing

Prevea360 Health Plan updates medical policies for Genetic Testing biannually on an ongoing basis. As genetic testing has increasingly become the standard of care, Prevea360 Health Plan is committed to the access and quality of these services for our members. 

Our current genetic testing policies were developed by our contracted vendor Concert Genetics, an industry leader in genetic testing technology assessment and policy development. To search for the genetic testing medical policies, visit the document library page and enter Genetic Testing in the “Search for” box.

Here are a few things to consider:

Although prior authorization is no longer required for genetic testing as of 7/1/2023 when utilizing providers allowed under the member’s plan, claims will still need to be coded correctly and services still need to be medically necessary based on coverage criteria. Claims may be denied if this information is not provided or accurate. 

Not all genetic tests are considered a covered benefit under the member’s plan. Please contact the Customer Care Center at 877-230-7555 to confirm the recommended testing is a covered benefit of the member’s plan.

  • General Approach to Genetic Testing Medical Policy MP9610, describes the general approach for any genetic testing not specifically addressed in another policy. It also serves as the general policy for genetic testing and will provide links to specific genetic tests.
  • Genetic tests must meet applicable evidenced based guidelines and be medically necessary. 
  • Genetic counseling and medical necessity requirements may be test specific, as identified within each medical policy.
  • Medical necessity criteria will be applied to Commercial HMO, POS, PPO and ASO members.
  • ASO members are excluded from any Genetic Counseling requirements.
  • For laboratories only — Every genetic test is assigned a genetic testing unit (GTU), a unique alphanumeric identifier for payers who utilize Concert Genetic services. This unique GTU may be found on the Concert Genetic Platform. Every genetic test has been assigned a GTU. Log in at concertgenetics.com to find the GTU for your requested genetic test.


Genetic counseling requirement

Certain tests require pre-test and post- test genetic counseling. Prior authorization is not required for referrals to a genetic counselor.

Genetic Counseling Resources

St. Vincent Genetic Counseling department can provide genetic counseling for Prevea360 Health Plan members.

Members can be referred to St. Vincent Genetic Counseling at 920-433-8559 (fax 920-431-3138). Additionally, if there are in-network providers who employ genetic counselors may continue to use a current process that may be in place to comply with Prevea360 Health Plan’s updated genetics testing medical policies where genetic counseling is required.

Prevea360 Health Plan recognizes the limited accessibility of genetic counselors. We've partnered with InformedDNA (IDNA) to provide telephonic genetic counseling services for Prevea360 Health Plan members. The goal is to improve member satisfaction and ease the burden for our providers. 

If no genetic counselors are available within your organization or there is an access issue, Prevea360 Health Plan’s member may be referred to InformedDNA (IDNA). Use the IDNA Cancer Genetic Counseling Referral form or the Cardiac Genetic Counseling Referral form to refer to IDNA.

Additional resources