Blue Cross NC Shifts BRCA Testing From Post-Service to Pre-Service Review

BRCA 1 and BRCA2 genetic mutations are associated with a significantly higher risk for breast and ovarian cancer. BRCA testing is an important screening tool and should be performed on those members who meet clinical criteria for coverage.

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) has maintained a medical policy titled “Genetic Testing for Breast and Ovarian Cancer” since 1997, which outlines the criteria that must be met in order to have the test covered.

Review for the necessity of BRCA testing has historically been provided after the tests have been ordered and received. Unfortunately, both the member and the ordering physician are negatively affected when the test is denied for coverage after it has already been performed.

To improve the member and physician experience in ordering BRCA tests, Blue Cross NC has decided to shift the review for medically necessity to a pre-service/prior plan approval requirement effective July 1, 2015. Requiring BRCA to be approved prior to service should minimize member and physician liability.

Participating Labs That Offer Full BRCA Testing

Additionally, Blue Cross NC has participating provider agreements with four in-network laboratories offering full BRCA testing for our members whose specimen is drawn in the state of North Carolina: Lab Corp, Quest, Solstas, and Counsyl. All four laboratories are CLIA licensed and provide comprehensive BRCA mutation analysis.

Ordering BRCA tests through an in-network lab lowers the cost-share for our members and helps to control premium prices. As an in-network provider, you are required by your Blue Cross NC provider agreement to refer our members to other in-network providers, including labs.

The transition from post-service to pre-service review will become effective July 1, 2015. For your convenience, there will be a fax form available online on the Prior Review page by July 1 that outlines the clinical coverage criteria and provides additional billing and coding information.