Insurance

Step 1: Medical Evaluation and Indication

1. Consultation with a Healthcare Provider: Begin by scheduling an appointment with a healthcare provider (typically a genetic counselor, geneticist, or specialist) who assesses your medical history and symptoms to determine if a genetic test is warranted.

2. Medical Necessity: The healthcare provider will determine if the genetic test is medically necessary based on your clinical presentation, family history, or other factors. They will document this in your medical records.

Step 2: Pre-Authorization and Insurance Verification​

1. Pre-Authorization: Many insurance plans require pre-authorization for genetic testing. Your healthcare provider's office or the laboratory running the test can initiate this process by submitting the necessary medical documentation.  If the laboratory running the test is initiating the process, it is important for your provider's office to submit their medical records along with your sample. 

Step 3: Test Selection and Laboratory

1. Select a Laboratory: Your healthcare provider will choose a reputable genetic testing laboratory for the specific test. Ensure that the selected laboratory is in-network with your insurance plan to maximize coverage.

2. Ordering the Test: The healthcare provider will place an order for the genetic test with the chosen laboratory, specifying the test type and any relevant clinical information.

Step 4: Sample Collection and Analysis

1. Sample Collection: Depending on the test, you may need to provide a blood, saliva, or tissue sample. This is typically done at a healthcare facility or through a specialized testing kit provided by the laboratory.  You can ask your provider if the chosen laboratory allows for saliva kits to be mailed directly to your home.

2. Laboratory Analysis: The laboratory will perform the genetic analysis, generating the test results.

Step 5: Documentation and Billing

1. Your provider's office may have the laboratory bill their office, which will in turn bill you.  This can help the preferred lab be billed as in-network, however it is important to ask the provider's office if you will be billed for the cost of the test if insurance doesn't approve the test.  

2. Your provider's office may have the laboratory bill your insurance directly.  This can be helpful to reduce a price mark-up from a provider's office, however it is important to make sure a prior-authorization (PA) and benefits investigation (BI) is performed prior to initiating the test.  This will allow you to know the estimated bill prior to proceeding.  

Step 6: Review of Coverage and Explanation of Benefits (EOB)

1. Explanation of Benefits (EOB): Once the claim is processed, your insurance company will send you an Explanation of Benefits (EOB). Review this document carefully to understand what portion of the test cost is covered, any deductibles, co-pays, or co-insurance you may owe, and any denials or appeals instructions.

Step 7: Financial Responsibility

1. Payment Responsibility: Pay any out-of-pocket costs, deductibles, co-pays, or co-insurance as indicated in the EOB.

Step 8: Appeals (if necessary)

1. Appeal Process: If your insurance provider denies coverage and you believe the test was medically necessary, you have the right to appeal the decision. Follow your insurance company's appeal process, and work with your healthcare provider to provide supporting documentation.

Step 9: Test Results and Follow-Up

1. Test Results: Once the test results are available, schedule a follow-up appointment with your healthcare provider to discuss the findings and any necessary next steps.

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Navigating the process of ordering and billing a genetic test through insurance can be complex, and it's essential to maintain clear communication with your healthcare provider and insurance company throughout. Be proactive in verifying coverage, understanding your financial responsibility, and pursuing appeals if needed to ensure you receive the necessary genetic testing and related care.

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Feel free to contact the Genetic Counselors of Missouri to see if your insurance covers genetic testing.  There are many different types of insurance within the state, but we will do our best to find out on your behalf!