Working Together to Improve the Member-Provider Experience: Member Concerns About Genetic Testing Costs and Coverage

September 19, 2018

Blue Cross Blue Shield of New Mexico (BCBSNM) is focused on improving our members’ experience when they access care. On occasion, a member or their representative may call BCBSNM to voice concerns and/or dissatisfaction with a provider or care received. The BCBSNM Quality and Accreditation Department is responsible for processing complaints from commercial and marketplace members regarding the quality of care and/or the quality of service that they receive from their BCBSNM participating providers. These complaints are investigated and tracked to identify trends and ideas to improve the member-provider experience.

BCBSNM will publish a series of articles throughout this year to address some of our members’ most frequent concerns and remind providers of some of their related contractual obligations. We hope that we can work together with you and your staff to improve the care that you furnish to your patients (our members).

This month we will explore the following question: Why am I being billed for genetic testing that my provider ordered?

With all the advances in medicine, it is difficult to sort through the multitude of laboratory tests available, especially genetic tests. It is important for members to understand the types of genetic tests that are covered under their plan and out-of-pocket expenses that may result.

First, let’s look at the Blues Provider Reference Manual for information on contractual responsibilities. Then we will look at the BCBSNM Medical Policies related to genetic testing.

2018 Blues Provider Reference Manual, Section 4, Professional Provider Responsibilities PDF Document, 4.5 Medical Policy and Member Benefits, Overview

“Providers are required to review BCBSNM medical policy information, as these policies may impact your reimbursement and your patients’ benefits.

Providers are responsible for being familiar with services that may not be covered by BCBSNM, such as procedures that may be considered experimental and/or investigational. If a procedure or diagnostic service is considered experimental and/or investigational, you must inform the member that they may incur financial responsibility.”

2018 Blues Provider Reference Manual, Section 4, Professional Provider ResponsibilitiesPDF Document, 4.5 Medical Policy and Member Benefits, 4.5.1 Experimental. Investigational or Unproven Services

“Experimental, investigational, or unproven services include any treatment, procedure, facility, equipment, drug, device, or supply not accepted as standard medical practice, as defined below. In addition, if federal or other government agency approval is required for use of any items and such approval was not granted when services were administered, the service is considered experimental and will not be covered.”

2018 Blues Provider Reference Manual, Section 13, Laboratory Services PDF Document, 13.2 Non-covered Services/Experimental, Investigational, or Unproven Lab Work

“It is the responsibility of the provider ordering potentially experimental, investigational, or unproven lab work to inform the patient that this lab work may be a non-covered service, and that the patient may incur financial responsibility for such testing. The ordering provider should obtain a signed Non-covered Services, Experimental, Investigational, or Unproven Lab Work Consent and Waiver form from the patient and include it with any experimental, investigational or unproven lab work that is sent to a lab. Contracted labs are responsible for making a consent and waiver form available to providers.”

2018 Blues Provider Reference Manual, Section 13, Laboratory Services PDF Document, 13.3 Genetic Studies

“Genetic studies are limited by medical policy and benefit language and may require preauthorization. Refer to Medical Policies related to genetic studies on our website.”

Clinical criteria for genetic testing may be found in the BCBSNM Medical Policies. Let’s take a closer look!

“eviCore healthcare’s Clinical Guidelines, Lab Management Program, provides the clinical guidelines for medical review of lab management services for HCSC. HCSC has incorporated eviCore healthcare’s clinical review criteria into its medical policies. eviCore healthcare is contracted with HCSC to provide preauthorization and medical necessity review of these tests and services for members enrolled in certain plans.

eviCore Molecular/Genetic Guidelines’ purpose is “To establish evidence-based definitions, decision support, medical necessity criteria, coverage limitations, and payment rules for molecular and genetic testing.””

Below are some recommendations that may assist your patients, our members, in understanding genetic testing and potential out-of-pocket expenses.


  • Become familiar with BCBSNM Medical Policies that may be applicable to treatment and care that you are considering. Discuss whether the genetic test is medically necessary. If so, has the criteria, based on BCBSNM Medical Policies been satisfied?
  • Encourage your patients to be aware of their coverage, benefits and networks. A call to a BCBSNM Customer Service Advocate (CSA) before services are furnished to understand payment requirements and the anticipated out-of-pocket costs is beneficial.
  • Phone numbers to reach BCBSNM customer service are found on the back of the Member ID card. If a member does not have their Member ID card, they may call:
    Commercial members: 1-800-432-0750
    Marketplace members: 1-866-236-1702
    Medicare Advantage members: 1-877-774-8592

  • BCBSNM Provider Network Representatives are available to assist contracted providers:
    Monday - Friday, 8 a.m. to 4 p.m. Phone: (505) 837-8800 or toll free at 1-800-567-8540
    Fax: 1-866-290-7718
    Provider Network Representatives PDF Document can tell you if another provider is contracted with BCBSNM for your patient’s particular BCBSNM health plan.