Laboratory Management Program

Last Updated: Friday, December 22, 2023

wny
neny

The Laboratory Management Program is not applicable to New York.

Highmark has partnered with eviCore to manage molecular/genomic, and non-molecular testing within the Laboratory Management Program. The Laboratory Management Program utilizes evidence-based policies, developed with trained experts, to ensure that the lab services provided to Highmark's members support clinically appropriate care and are medically necessary, in accordance with their benefit policy.

Highmark requires prior authorization for several molecular/genomic tests when performed in an outpatient setting for fully-insured Commercial, Affordable Care Act (ACA), and Medicare Advantage members.

These tests include:

Hereditary Cancer Screening
Carrier Screening Tests
Tumor Marker/Molecular Profiling
Hereditary Cardiac Disorders
Cardiovascular Disease and Thrombosis Risk Variant Testing
Pharmacogenomic Testing
Neurologic Disorders
Mitochondrial Disease Testing
Intellectual Disability/Developmental Disorders

Highmark requires claims review for several non-molecular tests when performed in an outpatient setting for fully insured Commercial, Affordable Care Act (ACA), and Medicare Advantage members. A prior authorization is not required for these tests.

These tests include:

Cardiovascular Disease Risk Panels
Allergy Testing
Drug Testing
Celiac Disease
Vitamin D Testing
Thyroid Testing

Highmark has adopted eviCore’s molecular/genomic, and non-molecular testing policies. Policies and a complete list of impacted procedure codes are available HERE.

wpa/ nepa
cpa/ sepa
de
wv

Learn More About the Laboratory Management Program

eviCore has a dedicated webpage for Highmark providers to conveniently access evidence-based clinical guidelines, the current CPT code list, important resources, and recent announcements. We encourage you to visit their site to ensure that you have the most current information:

eviCore Highmark Provider Resources

You can also find any updates about the Laboratory Management Program in our provider portal and future issues of Provider News.

Reference Materials

Laboratory Management Program Administrative Guide
- This guide includes a summary of all components of the Laboratory Management Program.
eviCore Prior Auth Quick Reference Guide

eviCore healthcare is an independent company that does not provide Highmark products or services and is solely responsible for the products and services described here.