Optima Health has partnered with Avalon Healthcare Solutions for Laboratory Benefits Management (LBM) in order to administer Avalon’s Routine Testing Management (RTM), a post-service pre-payment clinical claim editing program and Genetic Testing Management (GTM), a pre-service prior authorization program for genetic testing. The laboratory testing policies for both the RTM and GTM program are accessible through the links below. These policies have been modified for Optima Health’s various products to align with government program policies, rules, and/or state and federal contracts, but note that in case of conflict, the government program policies, rules, and/or state and federal contracts will take precedence.

Please note that policies with an asterisk (*) are listed here for review purposes only and are not currently being used to determine coverage. The effective dates for these Policies has not been determined at this time, but will be shared at least 60 day prior to their effective date. 

DISCLAIMER: Application of coverage criteria is dependent upon an individual’s benefit coverage at the time of the request. If there is a conflict between this Policy and any relevant, applicable government policy [e.g. Local Coverage Determinations (LCDs) or National Coverage Determinations (NCDs) for Medicare] for a particular member, then the government policy will be used to make the determination. For the most up-to-date Medicare policies and coverage, please visit their search website http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx  or the manual website