Insurance Billing

It’s no surprise that insurance coverage can be complicated, with policies and requirements varying greatly from plan to plan. GeneDx is here to support you and your patients through the process.

GeneDx accepts all commercial insurance, Medicaid, Medicare and Tricare plans. We are proud to be in-network with many national and regional health plans.* See the full list here.

Insurance carriers are increasingly covering exome and genome testing. But as with all medical tests, patients may still receive a bill if they have not yet met their yearly plan deductible or if their plan requires coinsurance. GeneDx offers a variety of Patient Access Solutions to help.

Insurance requirements

For all insurance types, the following documents should be included at the time of the test order to increase the chance of insurance approval and help reduce back and forth for you and your patients.

Please provide at the time of order:

Prior authorization, if obtained in advance
- A prior authorization is almost always required by insurance for genetic testing. GeneDx encourages ordering providers to obtain a prior authorization in advance of placing an order. However, in most cases GeneDx can submit the authorization request to insurance on behalf of the ordering provider through our third-party vendor, careviso. Click here to learn more.
Insurance-required prior authorization form, if applicable
Supporting documentation that demonstrates why the test is medically necessary, including:
- Documentation of why exome/genome is the most appropriate test for your patient based on their personal and family history (e.g., clinical notes and previous test results)
- Documentation of how testing results could potentially impact management, including explicit details and examples (e.g., clinical notes)
- If applicable, documentation that genetic counseling was performed (e.g., separate genetic counseling consult note or documentation of counseling by the ordering provider)
A copy of the patient’s primary insurance card (front and back)

Some insurance companies require additional documentation. Click into each section below to learn about the specific requirements for Medicaid and Tricare.

Medicaid-specific requirements

GeneDx accepts all Medicaid plans and coverage for exome sequencing is expanding. In certain states without explicit Medicaid coverage for exome sequencing, patients may be able to obtain coverage for testing through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program. Click here to see if this is an option in your state and to access the appropriate EPSDT attestation.

Tricare-specific requirements

GeneDx accepts all Tricare plans.

If a prior authorization (PA) is obtained in advance of placing the order, then proof of an approved PA should be included at the time of test order. If not obtained in advance, to ensure a smooth billing process and avoid delayed results, all of the following should be included at the time of the test order for patients with a Tricare insurance plan:

Tricare PCM referral document for all Tricare East and West members with Prime and U.S. Family Health Plan
One of the following:
- The appropriate Tricare Laboratory Developed Test (LDT) attestation form
  - Tricare East LDT form
  - Tricare West LDT form
- Supporting documentation that demonstrates why the test is medically necessary, including:
  - Documentation of why exome/genome is the most appropriate test for your patient based on their personal and family history (e.g., clinical notes and previous test results)
  - Documentation of how testing results could potentially impact management, including explicit details and examples (e.g., clinical notes)
  - If applicable, documentation that genetic counseling was performed (e.g., separate genetic counseling consult note or documentation of counseling by the ordering provider)

Prior authorization support with careviso

We understand that prior authorizations can be a challenging part of the insurance billing process, so we’ve partnered with a third party, careviso, to obtain prior authorizations on your behalf. careviso works directly with payors to obtain prior authorizations for your GeneDx test orders.

Some insurance companies, such as UnitedHealthcare and many Blue Cross Blue Shield plans, require ordering providers to complete enrollment with careviso in order to access their prior authorization services for patients with those insurance plans.

Get started with careviso here.

Plan-specific forms

Some insurance companies require specific forms for their plan members. Please see the forms page of our website to find and download this paperwork.

Insurance Forms

*Please note that network status is not a guarantee of coverage; some health plans may have specific requirements (i.e., prior authorization and/or letter of medical necessity) that must be met for in-network benefits to apply and for services to be covered.