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Health Insurance Coverage and Reimbursement Currently, insurance coverage policies are limited to node negative, estrogen receptor positive patients. It is unknown at this time whether node positive patients will be covered. Genomic Health will continue to work hard to assist you and your patients throughout the process of determining coverage, billing insurance, and assisting in the appeals of any denials. We are prepared to take formal assignment of benefits whenever possible and submit insurance claims on behalf of insured patients in the US for the Oncotype DX® assay. We do not expect institutions or healthcare providers to order this assay from Genomic Health and then bill third-party payers on their own, assuming the risks of reimbursement, except where required to comply with billing regulations or policies, or pre-existing contractual arrangements. Genomic Health is pleased that many payers, representing more than 175 million lives covered, have established favorable coverage policies for Oncotype DX in node negative, estrogen receptor positive breast cancer patients. These payers include Medicare (through a local coverage decision developed by the National Heritage Insurance Company which applies to all testing billed by our California facility), United Healthcare, CIGNA*, Aetna*, Kaiser Permanente, Health Net, Humana, Blue Shield of California, WellPoint §, and many others. We are committed to expanding coverage for the Oncotype DX assay and will continue to work with all major plans across the nation to establish favorable policies. Through our Genomic Access Program (GAP), benefits investigations may be performed to provide your patients information about their specific coverage and potential financial responsibility. Some insurers may require a prior authorization prior to the processing of the patient’s specimen. The GAP team can help facilitate this process for you. If coverage is denied our GAP team can appeal this denial on your patient’s behalf. However in those cases where all appeals are exhausted and the claim is not fully paid, the patient will ultimately be responsible for any balance remaining on the invoice. Genomic Health provides a comprehensive Financial Assistance Program for patients with financial hardship and a program for uninsured and underinsured patients. The reimbursement professionals at Genomic Health will do their very best to obtain coverage for this test, but they cannot guarantee success. For questions concerning reimbursement or financial assistance, please call Genomic Health Customer Service at 866-ONCOTYPE (866-662-6897). |
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