Insurance Alignment

Overview:

A primary initiative of PLUGS is insurance alignment. Coverage and reimbursement for laboratory testing are influenced by favorable evidence and medical coverage policies, successful navigation of preauthorization and denial-appeal workflows by providers, labs, and patients/families, and legislation mandating coverage under specific circumstances. Our efforts focus on relationship-building, increasing awareness of the challenges faced by providers, labs, patients, and payers, and proposing solutions and resources to support access to medically appropriate laboratory tests.

If you are a patient or caregiver please see additional resources here.

REQUEST FOR COMMENT: PLUGS Consensus Recommendations and Framework for Development of Payer Medical Necessity Policies

The purpose of the draft consensus statement is to enable the development of a consistent framework for payer medical necessity policies that reduces fraud, waste, and abuse while providing flexibility in medical practice and decreased administrative burden for all stakeholders.  The goal of this proposed framework is broader, future adoption by health plans and laboratory benefits managers as voluntary standards.

You are an important stakeholder in this space, and we welcome your feedback.  The final version of these recommendations and framework will be made publicly available on the PLUGS website. Please share with others who might also be interested in providing feedback.

Please share your feedback by August 20th, 2024

Medical Policies:

The following PLUGS® policies were developed by experts within the PLUGS network and are intended for use by insurance payers, laboratories, providers, families, and consumer groups to guide coverage and reimbursement for medically appropriate genetic tests. Microsoft Word versions available upon request.

Epilepsy Genetic Testing Policy
Rapid Genome Sequencing Policy
Genomic Sequencing in Rare Disease
Inherited Bone Marrow Failure Syndromes Policy
MELAS Genetic Testing Coverage Policy
MERFF Genetic Testing Coverage Policy
NARP Genetic Testing Coverage Policy
Mitochondrial Genetic Testing Coverage Policy
Mitochondrial DNA Deletion Syndromes Genetic Testing Coverage Policy
LHON Genetic Testing Coverage Policy
MNGIE Genetic Testing Coverage Policy


Tools for Providers

The following tools are intended to help providers, laboratory administration staff, and others navigate the preauthorization process while adhering to payer policies and utilizing available resources. The tools were created by a working group within the PLUGS Insurance Alignment Committee.

Are you a PLUGS member? Log in to see the full Preauthorization Toolkit for PLUGS Members here!