22-495m Cancer Patients Can Now Get Better Access to Biomarker Testing
Date: 06/17/22
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.
Patients with advanced stage cancer no longer require prior authorization for biomarker testing
Effective July 1, 2022, Senate Bill 535 amends Section 1367.665 of the Health and Safety Code, and Section 10123.20 of the Insurance Code, relating to health care coverage. This bill clarifies that prior authorization is no longer required for biomarker testing for either of the following:
- An enrollee with advanced or metastatic stage 3 or 4 cancer.
- Cancer progression or recurrence in the enrollee with advanced or metastatic stage 3 or 4 cancer.
This change does not apply to:
- Biomarker testing that is not for a U.S. Food and Drug Administration-approved therapy for advanced or metastatic stage 3 or 4 cancer.
By eliminating the need for prior authorization, patients can get better access to available testing and avoid dangerous treatment delays. For more information, refer to SB-535 Biomarker testing.
Billing diagnosis codes for cancer
Providers must bill applicable cancer or history of cancer diagnosis codes in the primary/principal position on the claim:
- Cancer diagnosis code: C00 through C96.Z.
- History of cancer diagnosis code: Z85 through Z85.9.
Additional information
Relevant sections of Health Net’s provider operations manuals have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library after logging in to Health Net’s provider website > Provider Library under Quick Links, or go directly to provider library.
If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email within 60 days, by phone or through the Health Net provider website.