What you need to know about Avalon for genetic testing

CDPHP^® is proud to announce a new laboratory benefit management program in collaboration with Avalon Healthcare Solutions (Avalon). CDPHP genetic testing policies will be enforced by Avalon through prior authorization starting January 18, 2022.

Providers of laboratory services (both referring and performing) will need to be aware of this new program, as collectively we have an obligation to ensure members and patients receive high-quality services at the most affordable costs.

Avalon is a licensed utilization review agent in New York state and is a fully-delegated vendor with NCQA UM accreditation. They provide a comprehensive genetic testing management (GTM) program managing outpatient laboratory services across all providers, including independent, physician office, and hospital-based labs. Their program requires a nurse or physician to review and determine if a prescribed test is medically appropriate. This assessment effectively prevents unnecessary, low-quality, and high-cost tests while ensuring labs are inputting codes correctly.

What’s changing?

Currently, CDPHP has one policy that addresses genetic and molecular diagnostic testing. With Avalon, we’ll have ~80 new genetic testing policies for prior authorization review.

These policies are supported by evidence-based medical science to improve alignment to laboratory science standards. Additionally, Avalon has an Independent Clinical Advisory Board (CAB) comprised of five prominent nationally renowned lab experts with medical expertise in fields of clinical pathology, laboratory medicine, medical and clinical molecular geneticist, specialists in bone and soft tissue tumors, biomedical engineering, and hematology.

Is there a new process?

Prior authorization for genetic testing will now be handled by Avalon Healthcare Solutions. A prior authorization request can be submitted to Avalon by phone, fax, or through the Avalon prior authorization system (PAS).

• Prior authorization decisions will be made by Avalon.
• You may continue your current process for genetic testing prior authorization, but please go through Avalon on the CDPHP provider portal to submit requests.
• Decision letters (approval and denial) will come from Avalon, as will automated approval phone calls.
• Denial notifications will come from a CDPHP utilization review nurse. If a denial is issued and a provider would like to do a peer-to-peer review, those will now be performed with a medical director at Avalon.
• Appeals will continue to process through CDPHP.
• Providers can contact Avalon at 1-844-227-5769 for any questions.

More details can be found here.