Fillable BRCA Precertification Information Request Form

Fill Online, Printable, Fillable, Blank BRCA Precertification Information Request Form Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

BRCA Precertification Information Request Form

On average this form takes 33 minutes to complete

The BRCA Precertification Information Request Form form is 7 pages long and contains:

  • 0 signatures
  • 82 check-boxes
  • 92 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Page 1 of 7
BRCA
Precertification Information Request Form
Applies to:
Aetna plans
Innovation Health® plans
Health benefits and health insurance plans offered and/or underwritten
by the following:
Allina Health and Aetna Health Insurance Company (Allina Health | Aetna)
Banner Health and Aetna Health Insurance Company and/or Banner Health and
Aetna Health Plan Inc. (Banner | Aetna)
Sutter Health and Aetna Administrative Services LLC (Sutter Health | Aetna)
Texas Health + Aetna Health Plan Inc. and Texas Health + Aetna Health Insurance
Company (Texas Health Aetna)
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including
Aetna Life Insurance Company and its affiliates (Aetna). Aetna provides certain management services on behalf of its affiliates.
GR-67606-4 (5-20)
Page 2 of 7 GR-67606-4 (5-20)
About this form
All BRCA tests require precertification. To initiate a request, you have to submit your request electronically. Or you can call our
Precertification Department. Failure to complete this form and submit all medical records we are requesting may result in the delay
of review or denial of coverage.
Effective May 1, 2020, this form replaces all other BRCA precertification information request documents and forms.
How to fill out this form
As the patient’s attending physician, you must complete all sections of this form. You can use this form with all Aetna health plans, including
Aetna’s Medicare Advantage plans. You can also use this form with health plans for which Aetna provides certain management services.
When you’re done
Once you’ve filled out this form, submit it and all requested medical documentation to our Precertification Department by:
(Preferred) Upload your information electronically on our secure provider portal at www.Availity.com.
Send your information via confidential fax to: 860-975-9126
Mail your information to: PO Box 14079
Lexington, KY 40512-4079
BRCA
Precertification Information Request Form
Or you can submit the completed form and the specimen sample to one of our network BRCA testing laboratories listed below. Then they’ll
submit the form to us.
Quest Diagnostics, Inc.
Fax the precertification form to 1-855-422-5181. Call BRCAvantage Concierge Services at
1-866-436-3463 or visit www.questvantage.com for more information
LabCorp
Fax the precertification form to 1-855-711-5699. For questions, call 1-855-488-8750 or send
email to BRCApriorauth@labcorp.com
Ambry Genetics
Fax the precertification form to 1-949-900-5501. Order collection and transportation kits from by
calling 1-866-262-7943 or online at www.ambrygen.com
Baylor Miraca Genetics Laboratories,
LLC
Fax the precertification form to 1-713 798-4197. Order collection and transportation kits by
calling 1-800-411-GENE or email help@baylorgenetics.com.
Counsyl
For more information, call 1-888-COUNSYL (1-888-268-6795), send an email to
support@counsyl.com or visit www.counsyl.com
GeneDx, Genpath, BioReference
Fax the precertification form to 1-201-421-2010. If you have any questions call 1-888-729-1206
or visit www.genedx.com
Invitae
Fax the precertification form to 1-415-276-4164. If you have any questions, call 1-800-436-3037
or email clientservices@invitae.com or visit www.invitae.com/en/request-a-kit/
Medical Diagnostic Lab, LLC
Fax the precertification form to 1-609-570-1062. If you have questions, call 1-877-269-0090 or
visit www.mdlab.com
Myriad Genetics Laboratories, Inc. Fax the precertification form to 1-801-584-3615. If you have questions, call 1-800-469-7423
Progenity
Progenity - Submit the completed BRCA precertification form with a Riscover patient specimen.
For questions or to receive specimen kits, call 855-293-2639.
Page 3 of 7 GR-67606-4 (5-20)
BRCA
Precertification Information Request Form
/ /
- -
What happens next?
Once we r
eceive the requested documentation, we’ll perform a clinical review. Then we’ll make a coverage determination and let you know
our decision.
How we make coverage determinations
For our Me
dicare Advantage members, we use CMS benefit policies, including national coverage determinations (NCD) and local coverage
determinations (LCD) when available, to make our coverage determinations If there isn’t an available NCD or LCD to review, then we’ll use
the Clinical Policy Bulletin referenced below to make the determination.
For all other members, we encourage you to review Clinical Policy Bulletin #227: BRCA Testing, Prophylactic Mastectomy, and
Prophylactic Oophorectomy before you complete this form.
You can find the Clinical Policy Bulletins and Precertification Lists by visiting the website on the back of the member’s ID card.
Failure to complete this form in its entirety may result in the delay of review.
Fax to: BRCA Precertification Department Fax number: 1-860-975-9126
Section 1: To be completed by ordering physician
If submitting request electronically, complete member name and ID only
Member name: Member ID:
Member address:
Member phone #: Member date of birth:
Biological Gender: M F Reference Number:
Physician name: Physician NPI number:
Physician phone number: Physician status: Participating Non-participating
Physician address:
IPA name: IPA NPI Number:
IPA address:
IPA phone #: 1-
Page 4 of 7 GR-67606-4 (5-20)
BRCA
Precertification Information Request Form
/ /
/ /
Member Name:
Member ID: Reference Number:
Section 2: Provide the following general information
Do not complete section 2 if submitting electronically
Laboratory name: Laboratory phone number:
Laboratory status: Partici
p
atin
g N
on
-
pa
r
ticipating Date of specimen collection:
ICD-10 code(s):
Section 3: Test menu
BRCA1/2 full gene sequence analysis (CPT 81163)
BRCA1/2 three mutation (187delAG, 5385insC, 6174delT) gene analysis, Ashkenazi Jewish Ancestry (CPT 81212)
BRCA1/2 three mutation (187delAG, 5385insC, 6174delT) gene analysis, Ashkenazi Jewish Ancestry WITH reflex to full gene
sequencing (CPT 812
12 or 81163)
BRCA 1/2 full large rearrangement (BART) analysis
1
(Medicare members only) (CPT 81164)
BRCA 1/2 full gene sequence analysis WITH full large rearrangement (BART)
1
analysis for hereditary cancer risk (Medicare
members only) (CPT 81162)
BRCA 1 or BRCA 2 known deleterious familial variant (BRCA 1: CPT 81215, BRCA 2; CPT 81217) Specify gene:
relationship: mutation:
BRCA1/2 testing to
determine PARP-inhibitor treatment (CPT 81162 or 81163);
Specify somatic or germline: test nam
e:
PARP-inhibitor consider
ed:
Total number and names of previously failed therapies:
Section 4: Personal cancer history
2
No personal history of breast
3
/ovarian
4
/pancreatic cancer
Personal history of breast cancer
3
- currently under treatment
Personal history of breast cancer
3
- treatment completed
Unilateral Bilateral Triple Negative
Age at diagnosis: Dat
e of diagnosis:
Stage:
Invas
ive ductal carcinoma (IDC) Invasive lobular carcinoma (ILC) Ductal carcinoma in situ (DCIS)
Pers
onal history of ovarian cancer
4
- currently under treatment
Personal history of ovarian cancer
4
- treatment completed
Personal history of pancreatic cancer
Other clinical history, please specify:
1
Aetna does not cover large rearrangement testing (BART) unless the member is covered by Medicare and meets criteria for comprehensive testing. There is inadequate information regarding
the frequency of large genomic re-arrangements in the United States populations to indicate that testing or re-testing for these specific mutations (e.g., the BART) is useful or effective in
managing the care of members, including those with a strong family history of breast, ovarian or pancreatic cancer.
In addition, Aetna does not cover multigene hereditary breast cancer panels that accompany BRCA testing because there is insufficient published evidence of their clinical validity and utility.
Information regarding this can be found in our Clinical Policy Bulletin (CPB): BRCA Testing, Prophylactic Mastectomy, and Prophylactic Oophorectomy available at www.aetna.com.
2
Members who seek coverage for BRCA1/2 testing for the benefit of OTHER family members must seek reimbursement of payment from the OTHER family member’s insurance carrier. BRCA
analysis for the medical management of OTHER family members is not a covered benefit for Aetna members.
3
The term breast cancer” includes both invasive and ductal carcinoma in situ (DCIS) breast cancers. Lobular carcinoma in situ (LCIS) is not included.
4
For purposes of these guidelines, ovarian cancer includes fallopian tube and primary peritoneal carcinoma.
Page 5 of 7 GR-67606-4 (5-20)
BRCA
Precertification Information Request Form
Member Name:
Member ID: Reference Number:
Section 5: Personal testing history
No previous BRCA genetic testing
Negative Ashkenazi Jewish panel testing
Negative BRCA 1/2 gene sequencing testing
Negative B
RCA 1/2 gene sequencing and large rearrangement testing
Other, please specify:
Previous testing lab:
Date of testing:
Results:
Section 6: Family cancer history and ethnicity
No known family history of breast
3
, ovarian
4
or pancreatic cancer
Ashkenazi Jewish Ancestry African American Asian
Caribbean Central/South American Eastern European
Hispanic Middle Eastern Native American
Northern European Pacific Islander Western European
Other
Relationship to patient
Maternal (M) or
paternal (P) side Type of cancer Age at diagnosis
Page 6 of 7 GR-67606-4 (5-20)
BRCA
Precertification Information Request Form
Member Name:
Member ID: Reference Number:
Section 7: Risk criteria category for FEMALES
Personal history of ovarian cancer
1
Date of ovarian cancer diagnosis: Month Year
Personal history of breast cancer
2
Date of breast cancer diagnosis: Month Year
1.
Breast cancer
2
diagnosed at age 50 years or younger; or
2. Breast cancer
2
is diagnosed at age 60 years or younger and is triple negative
3
3. Breast cancer
2
is diagnosed at any age, with any of the following:
a. At least one close blood relative
3
with epithelial ovarian cancer; or
b. At least two close blood relatives
3
on the same side of the family with breast cancer
2
; or
c. Member has two breast primaries
5
and has at least one close blood relative
3
with breast cancer
diagnosed at age 50 or younger; or
d. Close blood relative
3
with either breast cancer
2
at age 50 or younger or with epithelial ovarian cancer
1
(Medicare only); or
e. At least two close blood relatives
3
with pancreatic cancer or prostate cancer with Gleason score > 7 at
any age (Medicare only); or
f. Close male blood relative
3
with breast cancer
2
; or
g. First, second or third-degree blood relative
3
with a known BRCA1 or BRCA2 mutation
4
; or
h. Two close relatives
3
on the same side of the family with pancreatic adenocarcinoma at any age; or
i. Ethnicity is associated with higher mutation frequency (Ashkenazi Jewish)
5
.
NO personal history of breast
2
, ovarian cancer
1
or pancreatic adenocarcinoma (coverage excluded by
Medicare)
6
1.
Women with at least one first-degree blood relative
3
with:
a. epithelial ovarian cancer
1
or
b. breast cancer diagnosed at age 45 years or younger, or
c. bilateral breast cancer
5
2. Women with three or more close blood relatives
3
on the same side of the family with breast cancer; or
3. Women with at least one close blood relative
3
with:
a. male breast cancer; or
b. both breast
2
and epithelial ovarian cancer
1
. 4. Women with two close blood relatives
3
on the same side of
the family with:
a. epithelial ovarian cancer
1
; or
b. breast cancer
2
, one of whom was diagnosed at age 50 years or younger; or
c. breast cancer
2
in one relative and epithelial ovarian cancer
1
in another relative
5. Women of Ashkenazi Jewish descent with a first degree relative or two or more second degree relatives
on the same side of the family with breast or epithelial ovarian cancer
8
; or
6. Women with first, second- or third-degree blood relatives with a known BRCA1 or BRCA2 mutation
10
Women who do not meet any of the above criteria but are determined through both independent formal genetic
counseling and validated quantitative risk assessment tool
7
to have at least a 5% or greater pre-test probability of
carrying a BRCA1 or BRCA2 mutation. Note: In this category only, a 3-generation pedigree and quantitative risk
assessment results must be faxed directly to us at 1-860-975-9126. Pedigree template available on request.
Formal genetic counseling Yes No
Genetic counselor name and location (state):
Page 7 of 7
BRCA
Precertification Information Request Form
Member Name:
Member ID: Reference Number:
Section 8: Risk criteria category for both FEMALES and MALES
Individuals with a Personal history of pancreatic adenocarcinoma at any age
Section 9: Medical management (if patient tests positive)
Prophylactic oophorectomy Bilateral Tamoxifen chemoprevention
Prophylactic mastectomy Bilateral Increased breast surveillance
Other, please specify:
Section 10: Patient education
Consistent with the 1997 National Institutes of Health Consensus Statement on guidelines for care of patients with BRCA1
and BRCA2 mutations and American College of Medical Genetics guidelines, prior to testing and follow-up treatment, the
patient must give informed consent in accordance with applicable law. Also consistent with such guidelines, such informed
consent discussions should include at least the following:
1. Clarification of the patient’s increased risk status
2. Explanation of how genetics affects cancer susceptibility
3. Potential benefits, risk, and limitations of testing
4. Possible outcomes of testing (e.g., positive, negative or
uncertain test results)
5. Limited data regarding efficacy of methods for early
detection and prevention
6. Possible psychological and social impact of testing
7. Counseling regarding therapeutic options, including
limitations
Section 11: Read this important information
Any person who knowingly files a request for authorization of coverage of a medical procedure or service with the intent to
injure, defraud or deceive any insurance company by providing materially false information or conceals material information
for the purpose of misleading, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and
civil penalties.
Section 12: Sign the form
By signing this form, I certify that the member listed above has given informed consent in accordance with the guidelines and
risks above and that the BRCA analysis will be used to direct the medical management of this member.
Form completed by (please print): Title:
Physician Signature (required):
Contact Person: Phone Number:
1
For the purposes of these guidelines, fallopian tube and primary peritoneal carcinoma are included.
2
The term “breast cancer” includes invasive and ductal carcinoma in situ (DCIS) breast cancers. Lobular carcinoma in situ (LCIS) is not included.
3
Triple negative breast cancer is when the individual’s breast cancer cells test negative for estrogen receptors (ER-), progesterone receptors (PR-) and
human epidermal growth factor receptors (HER2-).
4
Validated quantitative risk assessment tools include BRCAPRO, Yale, UPenn I or UPenn II, BOADICEA and Tyrer-Cuzick IBIS (See CPB).
5
For Ashkenazi Jewish women who meet screening criteria, a screening panel for the founder mutations common in the Ashkenazi Jewish population
(multisite testing) is considered medically necessary. If founder mutation testing is negative, full gene sequencing (reflex testing) is considered medically
necessary only if member meets the criteria described above.
Medicare does not cover BRCA genetic testing in the absence of a personal history of breast or ovarian cancer, since it considered to be screening and is
specifically excluded by Medicare.
GR-67606-4 (5-20)
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

BRCA Precertification Information Request Form

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 28 June 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document