CareSource Laboratory Testing Policies

CareSource has partnered with Avalon Healthcare Solutions for laboratory benefits management (LBM), including Routine Testing Management (RTM), a post-service pre-payment clinical claim editing program for routine lab testing, and Genetic Testing Management (GTM), a pre-service prior authorization program for genetic testing. Both the RTM and GTM programs are based on ensuring compliance with the lab policies accessible through the links below. These policies provide guidance on clinically appropriate laboratory testing. These policies have been modified for CareSource’s various products to align with government program policies, rules and/or state contracts, but note that in case of conflict the government program policies, rules and/or state contracts will take precedence.  

The RTM program introduces NO new administrative requirements for providers. Policy compliance is determined after the claim is filed and based on fixed criteria as described in the policies.

The GTM program is a prior authorization program. For specific genetic testing procedures, prior authorization must be approved prior to the service being rendered. All CareSource prior authorization requirements, including lists of qualifying procedure codes by product, can be found on caresource.com.

Click on product name to access relevant policies.

Product

Initial Effective Date for RTM

Initial Effective Date for GTM

07/01/2021

01/01/2022

01/01/2022

01/01/2022

01/01/2022

01/01/2022

12/01/2021

01/01/2022

01/01/2022

01/01/2022

01/01/2022

01/01/2022

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