Using Commercial Insurance
While navigating the insurance process can be complicated, we’re here to help make it easier.
Insurance billing process
While navigating the insurance process can be complicated, we’re here to help make it easier. The below steps will guide you through what’s needed during the ordering process and how to obtain the patient’s estimated financial responsibility by performing a benefit investigation (BI).
Placing your order
To help ensure a smooth testing process without unnecessary delays, visit the GeneDx Provider Portal to initiate an order and perform a BI. For billing purposes and to facilitate any necessary prior authorization, submit the following information, if available, along with an order:
- ICD 10 diagnosis code(s) to the highest level of specificity
- Prior authorization reference number if already initiated, or, if approved, the insurance letter of prior authorization approval
- Clinical documents, including the summary from genetic counseling appointment
- Summary of patient’s clinical diagnosis/presentation
- Pedigree or summary of three-generation maternal and paternal family history
You can submit all information quickly along with the order in the GeneDx Provider Portal. Otherwise, the information can be sent with your patient’s specimen(s) or directly to our Billing Missing Information Team (fax: 1-201-421-2304, email@example.com).
New instant BIs!
We’re making it faster and easier for you to conduct a BI. Our new BI process is completed within the GeneDx Provider Portal, and in most cases, you’ll get an immediate result. For the rest, the BI will be returned to the portal, usually within 3-5 business days.
Patients should be reminded that any BI is an estimate only of the out of pocket amounts that patients may owe for their laboratory services. Patients should contact their insurance companies or health plans directly for confirmation of their out of pocket obligations.
As part of the BI process, a personalized Patient Letter is available for you to download and share with your patient. It includes their out-of-pocket estimate, self-pay pricing, and payment assistance information to aid their testing decision.
Once an order is submitted and a specimen arrives at the lab, we will proceed with the testing and bill according to the test requisition. Your patient will be financially responsible for any out-of-pocket amount as determined by their health insurance provider.
If a patient’s health insurance plan requires prior authorization (PA) or medical pre-certification, the test will be put on hold until an approved PA is obtained.
If assistance is needed with prior authorization, contact our Prior Authorization Team at firstname.lastname@example.org. In some cases, the following GeneDx numbers may be needed to complete PA paperwork: EIN: 20-5446298 NPI: 1487632998.
- If any information necessary to submit the prior authorization is missing, our Missing Info Team will reach out to you to request the documents.
- To expedite, send information directly to our Billing Missing Information Team – Fax: 1-201-421-2304, email@example.com
The GeneDx Prior Authorization Team will reach out to the patient/guardian to inform them of the PA process. Please note that an approved PA does not guarantee insurance coverage and does not change the estimated BI amount.
Once testing has been performed and a claim submitted to the patient’s health insurance company, the patient’s health insurance company will send an Explanation of Benefits (EOB) letter. We will send a bill, and a claim submitted to the patient’s health insurance company, to the patient for the member financial responsibility amount indicated on the EOB.
Tip: Patients do not need to make any payment until they receive a bill from GeneDx
Patients who are eligible, apply for, and are approved for the Financial Assistance Program (see below) will receive a second bill with the adjusted amount.
Financial Assistance Program
Helping to Make Genetic Testing Accessible
GeneDx understands that at a time when a patient may be facing many other medical expenses, working genetic testing into your budget may be challenging. That’s why we offer a Financial Assistance Program (FAP) to assist qualifying, eligible patients. Available to patients using commercial insurance, the FAP can, if approved, reduce the amount owed for the patient responsibility as specified on the explanation of benefits (EOB).
Patients can apply for FAP prior to or during the ordering and testing process. If approved, a final bill from GeneDx will reflect the adjusted amount owed.
The FAP is not available for:
- Certain commercial health insurance plans
- Any federally or state-funded insurance plans (e.g. Medicare, Medicaid, Tricare)
- Patients utilizing self-pay
How to apply
- Download the Financial Assistance Application.
- Complete the application.
- Gather required financial documents.
- Fax or mail the completed application and documents.
- GeneDx will contact the patient to let them know if they are approved.