Knowledge Base
Practical guides on payer policies, prior authorization, denials, and reimbursement, written for genetic labs, diagnostics, and oncology revenue cycle teams.
Fundamentals
What's Actually Covered as "Preventive" Under the ACA
The ACA's $0 preventive coverage is real. So are the four conditions that have to hold for it to apply. What's covered, what gets billed, and how to appeal.
Read article →The Five Health Insurance Plan Types Explained
HMO, PPO, HDHP, POS, EPO. What each plan type controls about your bill, with KFF 2025 enrollment data and a side-by-side comparison.
Read article →LCD vs. NCD: How Medicare's Two Coverage Determinations Actually Decide Your Claim
A National Coverage Determination (NCD) is issued by CMS and applies across all of Medicare; a Local Coverage Determination (LCD) is issued by a Medicare Administrative Contractor and applies only within its jurisdiction. This page explains the difference, how they interact, and why molecular and diagnostic claims must satisfy whichever determinations apply.
Read article →Modifier 25 Explained: Why Your "Free" Checkup Got a Bill
Modifier 25 is the code that turns a no-cost preventive visit into a billed one. When it is appropriate, when it is questionable, and how to appeal.
Read article →Prior Authorization vs. Precertification vs. Predetermination: What Each Term Means and Why It Decides Whether You Get Paid
Prior authorization, precertification, and predetermination are all pre-service review processes, but they differ in whether they are required and whether they bind the payer on payment. Knowing which one a given payer applies to a given test is essential to getting reimbursed.
Read article →What Is Prior Authorization? A Practical Guide for Genetic Labs and Oncology RCM Teams
Prior authorization is a payer requirement that providers obtain advance approval before delivering certain services, drugs, or tests, and understanding its mechanics is essential for minimizing delays and denials in genetic testing and oncology.
Read article →Operations
AI in Prior Authorization: What It Means for Diagnostics and Molecular Labs
Payers and providers are both deploying AI in utilization management and prior authorization, drawing new regulatory scrutiny in 2025-2026. Here is what the trend means specifically for diagnostics and molecular labs, and how to tell trustworthy automation from a black box.
Read article →Build vs. Buy: Keeping Payer Policy Current for a Molecular Lab
Every molecular lab tracks payer policy somehow, with analysts, spreadsheets, a billing vendor, or software. Here is an honest framework for deciding whether to build that capability or buy it, and what the decision actually hinges on.
Read article →CMS-0057-F: What the Prior Authorization Final Rule Actually Changes for Diagnostic and Molecular Labs
CMS-0057-F sets prior authorization decision clocks of 72 hours for expedited and 7 calendar days for standard requests starting January 1, 2026, requires specific denial reasons, and mandates four FHIR APIs generally by January 1, 2027. Here is what that means for a lab's molecular PA and appeals workflow.
Read article →How to Track Payer Policy Changes Without a Full-Time Analyst
Payers update medical policies constantly and rarely alert you, here's a lean system for catching changes before they turn into denial patterns.
Read article →Genetic Testing
Why an FDA Companion Diagnostic Is the Cleanest Path to Medicare Coverage for an NGS Test
Under Medicare's NCD 90.2, an NGS test that is FDA-approved or cleared as a companion diagnostic and used on-label for the patient's cancer has a defined national coverage pathway. Here is how that pathway works, why it is the most predictable route to payment, and where it stops.
Read article →Genetic Testing Prior Authorization: A Step-by-Step Playbook
Genetic testing PA fails most often at the documentation step, this playbook walks through every stage of the workflow for hereditary cancer panels, somatic profiling, and pharmacogenomics.
Read article →Liquid Biopsy and ctDNA Reimbursement: How Medicare Covers (and Denies) Plasma-Based Genomic Profiling
FDA-approved companion-diagnostic liquid biopsies have a defined Medicare pathway, while screening and many early-stage uses remain investigational. Coverage turns on the test, the indication, and the patient's stage.
Read article →MCED Coverage Reality Check: Where Galleri and Multi-Cancer Screening Actually Stand With Payers
Multi-cancer early detection tests like Galleri are commercially available but largely uncovered by Medicare and commercial payers as of mid-2026. This article explains why, where FDA review and federal legislation stand, and what an established coverage pathway looks like by comparison.
Read article →MRD Testing and Medicare Coverage: Why 'Covered' Depends Entirely on the Cancer and the Question Being Asked
Medicare covers molecular residual disease testing, but not as a blanket assay benefit. Coverage is granted indication by indication through MolDX Local Coverage Determinations, and getting paid depends on matching the exact cancer, stage, and clinical use the current policy describes.
Read article →NCD 90.2 Decoded: When Medicare Covers Next-Generation Sequencing for Cancer
Medicare's national coverage rule for cancer NGS sounds simple until you read it closely. Here is the exact patient profile that triggers coverage under NCD 90.2, how germline and companion-diagnostic testing fit, and the three things that most often get an otherwise-covered test denied.
Read article →Somatic vs. Germline Testing: Two Tests, Two Medicare Coverage Frameworks
Somatic and germline cancer tests can run on the same patient, sometimes the same sample, yet Medicare governs them through different coverage logic. Here is what each test answers, which framework applies under NCD 90.2, and why a claim must be matched to the right one.
Read article →Denials
Denials 101: A Taxonomy of Denial Reasons and How to Escalate Each
Not all denials are equal, understanding the specific reason code behind a denial determines which escalation pathway gives you the best odds of reversal, especially for genetic testing and oncology claims.
Read article →The 7 Most Common Claim Denial Reasons (and How to Fix Each)
Seven denial types cover the vast majority of claim rejections in genetic testing and oncology, here's the fix for each, not a general appeals strategy.
Read article →Why Molecular and Genetic Test Claims Get Denied (and How to Prevent It)
Most molecular and genetic test denials are operational, not clinical. Here is what the peer-reviewed data shows about denial rates, who gets denied most, and the fixes that prevent it.
Read article →Payer Playbooks
eviCore Guidelines for Oncology: What Practices Need to Know in 2026
eviCore manages oncology PA reviews for Cigna, Aetna, BCBS affiliates, and UHC Medicare Advantage, and their clinical pathways are different enough from standard payer policies that practices need a separate playbook.
Read article →UnitedHealthcare Prior Authorization Requirements: A 2026 Guide for Specialty Practices
UnitedHealthcare's PA requirements for specialty labs and oncology have expanded significantly, here's how to navigate their portals, policies, and timelines without burning your staff.
Read article →Reimbursement
Gold Carding: What It Is, Which Payers Offer It, and How to Qualify
Gold carding is a payer program that exempts high-performing providers from prior authorization requirements for specific services, and for genetic labs and oncology practices with strong approval track records, it can eliminate weeks of administrative friction.
Read article →How to Get a Molecular Test Covered: A Practical Market-Access Roadmap
Getting a new molecular or genetic test from validated to paid runs through MolDX registration, a DEX Z-Code, a technical assessment, coding and pricing, and commercial payer coverage. This roadmap walks each stage and what it actually takes.
Read article →The 14-Day Rule, Plain English: Who Bills Medicare for a Molecular Test, and When
Medicare's laboratory date-of-service policy decides whether your lab bills Medicare directly or has to chase a hospital for payment. A 2018 exception lets the performing lab bill Medicare directly for certain molecular and ADLT tests on hospital-outpatient specimens, but only when specific conditions are met.
Read article →Lab Billing 101: CPT, MAAA, and Z-Codes for Molecular Diagnostics
Molecular lab billing uses CPT Tier 1, Tier 2, MAAA codes, and DEX Z-codes, and choosing the wrong one gets your claim denied before a human ever reads it.
Read article →The MolDX Z-Code, Explained: When You Need One and How the Process Works
For labs billing molecular tests, the DEX Z-Code has gone from paperwork to a hard claim gate. Here is what a Z-Code is, when you need one, how to get it, and why having one still does not guarantee you get paid.
Read article →Pharmacogenomic Testing Coverage: When Medicare Pays for PGx and When It Denies
Pharmacogenomic coverage is narrow and gene-drug-specific. Medicare and its MolDX contractors generally pay when a PGx test guides a drug the patient is actually taking or actively considering, and routinely deny pre-emptive panels ordered with no drug in play. Here is how that line is drawn and where claims fall apart.
Read article →State Biomarker-Testing Coverage Laws: A 2026 Reference for Labs and Clinics
More than two dozen states have enacted laws requiring health plans to cover biomarker testing supported by medical evidence, but those mandates generally do not reach self-funded ERISA employer plans. This reference explains what the laws require, who they bind, and why coverage still varies in practice.
Read article →What Claim Denials Actually Cost a Molecular Lab
Denials are not a billing nuisance, they are a margin problem that compounds, and for molecular labs the rate is rising even as coverage expands. Here is the evidence, and where the money actually leaks.
Read article →Appeals
How to Write a Prior Authorization Appeal Letter That Actually Works
A PA appeal letter fails or succeeds based on how directly it addresses the denial reason, here's how to structure one that payers actually reverse.
Read article →Peer-to-Peer Reviews: How to Win Them
A peer-to-peer review is your best shot at reversing a medical necessity denial before you spend weeks on a written appeal, here's how to prepare for and run one.
Read article →Step Therapy Override Appeals: When and How to File
Step therapy requirements block specialty drug access when a payer says you must try a cheaper option first, but override rights are real, and so is the legal framework behind them.
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