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Use Case

Genetic Testing

How Avalon modernizes genetic test management for health plans and labs with an evidence-based, end-to-end model.

Proven Impact

Challenge

Genetic testing has grown too complex for traditional oversight models:

175,000+ tests on the market, with 10+ added daily

Increased waste and fraud from inappropriate utilization

Delayed or inconsistent coverage decisions

Fragmented lab access and misaligned test adoption

Rising regulatory scrutiny around prior authorization

These issues drive cost, create compliance risk, and strain both payers and labs.

Avalon

Avalon’s Approach

Avalon turns adopted evidence-based lab policies into guidance to ensure genetic testing is medically appropriate.

For Health Plans

  • Science-backed coverage criteria developed by laboratorians, geneticists, and an independent Clinical Advisory Board
  • Gold Carding & PA relief for top-performing labs using NCQA-aligned audits
  • NCQA-accredited utilization management to ensure consistent, evidence-based decisions
  • Real-time lab network oversight for utilization patterns, performance tracking, and audit reviews
  • Claims-to-auth matching using advanced automation to reduce manual reviews and improve accuracy
  • Compliance oversight to address evolving regulatory requirements without adding administrative burden

For Labs

  • AvalonSelect Genetic Network (ASGN): Streamlined access to multiple payers through a single agreement
  • Transparent reimbursement: National fee schedules, direct contracting, and claims reconciliation for predictable payments
  • Lab Technology Evaluation (LTE): Accelerated policy development for new tests
  • Dedicated lab support: Ongoing onboarding, coding clarity, and appeals assistance

Proven Impact

Health plans and labs partner with Avalon to overhaul their genetic test management.

For Health Plans

Shift to Avalon’s science-based coverage model

Implement claim-to-auth specificity, reducing manual claim reviews

Reduce genetic testing spend while increasing policy adherence

Achieve full compliance with state biomarker mandates without cost inflation

For Labs

Qualify for Gold Carding program, which removes PA requirements

Participate in Avalon’s quarterly quality audits with >95% compliance

Evaluate proprietary tests via LTE to gain policy inclusion across payers

Cut claims denial rate and improve revenue predictability through national fee schedule and quarterly reconciliation reports

Key Capabilities Used

Impact

For Health Plans

$0.50- $0.80

PMPM in savings

3:1

ROI from optimized test utilization

Streamlined

compliance with PA reform and biomarker mandates

Increased

provider satisfaction and reduced appeals

Impact

For Labs

30–40%

reduction in administrative overhead

Faster

test credentialing and multi-plan coverage

Improved

reimbursement clarity

Recognition

as a high-quality provider with fewer authorization barriers

Precision testing requires precision management.

Talk to us about joining ASGN, partner with us, or submit a test for evaluation.

Let’s Talk

Interested in Joining the Avalon Network?

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