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​​​​​​​​​​​Utilization Management by CareCore National, LLC d/b/a eviCore healthcare (eviCore) for Genetic/Genomic Testing and Certain Molecular Analyses and Cytogenetic Tests

AmeriHealth has delegated utilization management of genetic/genomic testing and certain molecular analyses and cytogenetic tests to CareCore National, LLC d/b/a eviCore healthcare (eviCore) for most members enrolled in its AmeriHealth New Jersey and Pennsylvania Medicare Advantage​ products. This utilization management program through eviCore encompasses precertification and/or prepayment review as follows:

  • Precertification/preapproval is required for certain genetic/genomic tests.
  • All genetic/genomic tests, along with certain molecular analyses and cytogenetic tests, are reviewed prior to claim payment.

eviCore utilizes its Lab Management Program Clinical Guidelines* for medical necessity determination related to the delegated genetic/genomic tests and certain molecular analyses and cytogenetic tests. For more information, refer to the current version of Policy #MA06.034: eviCore Lab Management.

* eviCore healthcare follows Medicare rules when applying coverage decisions for laboratory testing under Medicare Advantage plans. For example, applicable National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs), or Molecular Diagnostic Services (MolDX) program will be used firstly during utilization management decisions. Additionally, eviCore uses multiple sources to develop their Lab Management Program Clinical Guidelines, including consultation with the Company, peer-reviewed literature, evidence-based guidelines and recommendations from national and international medical societies, and evidence-based medical research centers, including, but not limited to, the National Comprehensive Cancer Network (NCCN), the American College of Obstetrics and Gynecologists (ACOG), the American College of Medical Genetics (ACMG), and the American Society of Human Genetics (ASHG).

Click here to access the eviCore Lab Management Program Clinical Guidelines for AmeriHealth New Jersey.​​