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Ordering and Billing Questions

General Insurance

Reaching out to the insurance company is the best way for a patient to obtain their coverage and estimated out-of-pocket expenses. By calling the insurance company and providing the information below, the insurance company can provide the patient with a good idea of what to expect in terms of coverage and out-of-pocket expenses. They can also inform the patient of any special requirements like authorization.

  • Provider Name – Pathway Genomics
  • Provider NPI – 1689818627
  • Provider Tax ID – 262897408
  • Test Name
  • Test’s CPT Codes

If preferred, Pathway Genomics can reach out to the insurance company on a patient’s behalf. All we will need is the patient’s:

  • Full Name
  • Insurance ID number
  • Provider contact phone number is located on the back of the patient’s insurance card or the customer service number if the provider number is unavailable
  • Patient’s date of birth
  • Test Name(s)
  • Secure preferred contact phone number

Regardless of what the insurance company estimates a patient’s out-of-pocket will be, Pathway Genomics is ready with a variety of financial assistance options to assist with managing costs.

Please allow us to assist with any questions: billing@pathway.com | p: 877.559.1590 | f: 858.866.9751 | Mon-Fri 8am-5pm PST.

Preauthorization is also known as prior authorization, prior approval, or precertification and it is another step that some insurance companies request to be completed before a procedure is initiated. It involves sending the insurance company a packet of information often including: insurance specific preauthorization request form, copy of the patient’s medical history, statement of medical necessity from the physician, diagnosis codes, progress notes, etc.

Pathway Genomics works closely with physician offices and insurance companies to obtain preauthorization for our cancer tests. One way we facilitate this is by making specific forms easily available to physician offices.

Please note that preauthorization is not a guarantee of coverage.

Please allow us to assist with any questions: billing@pathway.com | p: 877.559.1590 | f: 858.866.9751 | Mon-Fri 8am-5pm PST.

After Pathway Genomics files a claim, your insurance company may pull funds directly from your health account to pay Pathway Genomics.  It is recommended, if you have one of these accounts that you opt out of automatic payment prior to submitting a sample for testing.

Some insurance plans will make the patient responsible for any non-covered charges and pull funds directly from the HSA/FSA/HRA. Pathway Genomics only bills patients for “Allowed” charges, which are applied to Deductible, Co-Insurance and/or Copayments.

If a patient is enrolled in an FSA, HSA, HRA or other type of medical spending account, Pathway Genomics is not responsible or liable for any medical spending account automatic deduction. Pathway Genomics recommends, to prevent this, consider removing any automatic deductions prior to submitting a sample for testing. If not, the patient’s account may be debited automatically by the patients Insurance company to pay Pathway Genomics. This automatic payment may be a vastly different amount than the final patient responsibility as determined by Pathway Genomics.

Pathway Genomics does not have the ability to reverse or refund these payments or other reimbursed amounts. Contacting any insurance carrier or employer in advance of services regarding coordination of benefits issues that may impact such an account is solely the responsibility of the patient.

How does Pathway Genomic determine my Patient Responsibility?

Patients will be responsible for their Deductible, Co-Insurance and Copayment, as determined by their insurance company.

Deductible: The amount a patient must pay prior to having benefits paid by insurance. Deductibles may be required for both in-network and out-of-network services.

Co-Insurance: A patient’s share of the cost of a service, often a percentage of the Allowed Amount.  Co-Insurance begins after the Deductible amount has been met.

Copayments: A fixed amount (e.g. $20) required from a patient when seeking services from a provider.

Allowed Amount: The amount determined by the insurance company, also known as an “eligible expense” or “negotiated rate”. Insurance will use that price to determine a patient’s benefits. There is often a difference between the Allowed Amount and the “Billed Amount” which is the amount a medical provider charges for a service (e.g. a doctor may bill $20 for a flu shot, however, the insurance Allowed Amount is $15. The insurance will apply the member’s benefits to $15). Pathway Genomics does not bill the difference between the Allowed Amount and the Billed Amount to the patients.

We understand that there are a variety of financial needs and we would be happy to work with you to provide some options.

Please allow us to assist with any questions: billing@pathway.com | p: 877.559.1590 | f: 858.866.9751 | Mon-Fri 8am-5pm PST.

Throughout the claims and appeals process, Pathway Genomics will work closely with the insurance company to facilitate gathering and coordinating everything it requires to ensure that the patient’s benefits have been properly applied. This process may take several months and often involves requests for additional information or follow-up from both the patient and physician’s office.

For example, some insurance companies require written consent from a patient before they will review his or her medical records. Pathway Genomics may then send a letter to the patient requesting that consent.

It is important to review and respond to the communications from Pathway Genomics in a timely manner as most insurance companies have a time limit to how long they will hold a claim and/or appeal.

Please allow us to assist with any questions: billing@pathway.com | p: 877.559.1590 | f: 858.866.9751 | Mon-Fri 8am-5pm PST.

Pathway Genomics will send a claim to your insurance company.  It may take 4-6 weeks for the insurance company to respond with payment, partial payment, denial, or a request for additional information.

After sending additional information to the insurance company, it may take 4-6 weeks for the adjudication process. If a claim is not paid in full, Pathway Genomics may initiate an appeals process with your insurance company. This process may take another 4-6 weeks.

This is why it may take months for you to receive a bill from Pathway Genomics.

Please allow us to assist with any questions: billing@pathway.com | p: 877.559.1590 | f: 858.866.9751 | Mon-Fri 8am-5pm PST.

As a normal part of the billing process, most patients will receive an Explanation of Benefits, commonly referred to as an EOB. It is the comprehensive notice from an insurance company that details how they have processed a particular claim or appeal on medical services provided.

There are times when Pathway Genomics will provide the insurance company additional information after the claim was processed. In such cases, a patient may receive several EOBs for the same service. Each EOB will explain how the insurance company processed each new set of information received.

An EOB is often mistaken for a bill as it has many components of a bill, including wording like “patient responsibility” or “you owe”. However, it is not a bill, but rather a report on where a claim stands along the claims and appeal process.

Payment is not required unless you receive a statement directly from Pathway Genomics. And as each process can take a varied amount of time, a statement from Pathway Genomics may be several months or more, after the date of service.

Please allow us to assist with any questions: billing@pathway.com | p: 877.559.1590 | f: 858.866.9751 | Mon-Fri 8am-5pm PST.

Instead of paying Pathway Genomics directly, some insurance companies will send a check to the patient, making it the patient’s responsibility to pass on the payment.

On the back of the check, please endorse with “Payable to Pathway Genomics” and mail the check as well as a copy of the EOB to:

Pathway Genomics

PO Box 101580

Pasadena, CA 91189-1580

Please allow us to assist with any questions: billing@pathway.com | p: 877.559.1590 | f: 858.866.9751 | Mon-Fri 8am-5pm PST.

Once a patient’s test has been completed, a claim is submitted to the insurance company for processing under the member’s benefit plan. Pathway Genomics will attempt to send the payer any requested supporting documentation and/or file an appeal, if reasonable.

Throughout the claims and appeals process, Pathway Genomics will work closely with the payer to facilitate gathering as well as coordinating everything the payer requests, in order to ensure that the patient’s benefits have been properly applied. This process may take several months and involve requests for additional information or follow-up from both the patient and physician’s office.

At the conclusion of the claims and appeals process, the payer will let us know the Allowed Amount as well as any Deductibles, Coinsurance, and/or Copayments. At most, a patient will only be responsible for their Deductible, Coinsurance, and/or Copayments. It is important to note that Pathway Genomics will reduce the test price to match the payer’s Allowed Amount for the test. You may see adjustments, such as those pertaining to the Allowed Amount on your patient statement.

We accept both credit cards as well as checks for statement settlements. For credit cards, please use the personalized information found on your individual statement. For checks, please notate your account number on the check and send them to: Pathway Genomics, P.O. Box 101580, Pasadena, CA 91189-1580. We understand that there are a variety of financial needs and we would be happy to work with you to provide some options.

Please allow us to assist with any questions: billing@pathway.com | p: 877.559.1590 | f: 858.866.9751 | Mon-Fri 8am-5pm PST.

Billing Terms & Definitions

The shared costs covered by the patients’ health insurance plan that the patient pays out-of-pocket. This generally includes deductibles, co-insurance, and co-payments, or similar charges. It does not include premiums, balance-billed amounts for non-network providers, or the cost of services, which are not covered.

A deductible is the amount the patient owes for covered health care services before the health insurance plan begins to pay. For example, if a patient’s deductible is $1,000 per year, the insurance plan will not pay anything until the patient has met their $1,000 deductible for covered health services subject to the deductible for that year. The deductible may not be applied to some services, such as preventative services, dependent upon the patient’s plan.

A patient’s shared costs of a covered health care service, calculated as a percent (for example, 20 percent) of the allowed amount for the service; patients pay co-insurance plus any deductibles owed. For example, if the health insurance plan’s allowed amount for an office visit is $100 and the patient has met their deductible, their co-insurance payment of 20 percent would be $20. The health insurance plan pays the rest of the allowed amount.

A fixed amount (for example, $15) the patient pays for a covered health care service, usually when he or she receives the service. The amount can vary by the type of covered health care services.

Balance billing occurs when physicians or other providers and hospitals or facilities, who are not contracted with an HMO or preferred provider benefit plan (often referred to as a “PPO”), bill for the difference between the billed amount and the amount the health plan believes to be adequate reimbursement (allowable amount).

Note: Pathway Genomics does NOT balance bill patients for testing performed.

ICD-10 and CPT Codes

ICD-10 is a set of codes used by medical providers to describe the medical diagnoses/ conditions of his or her patients. When it pertains to genetic testing, it is important for the medical provider to supply the diagnostic laboratory with the indication to allow for testing, in the form of an ICD-10 code. For example, if the provider is ordering comprehensive BRCA1 and BRCA2 analysis (BRCATrueTM) on their patient due to a diagnosis of early-onset breast cancer, an appropriate ICD-10 code to utilize might be 174.9. It is important to remember to always utilize ICD-10 codes that support the reason for genetic testing so that an insurance company can understand why the testing was ordered. To aid in selecting an appropriate ICD-10 code for testing, Pathway Genomics has provided some of the more commonly used ICD-10 codes on the back of the test requisition form. However, we understand that this list is not comprehensive, thus please be sure to provide an ICD-10 code that best describes your patient and the indication for testing.

If you are not sure what ICD-10 code is best to use for your patient, you can input your patient’s diagnosis here to receive the proper ICD-10 code.

Pathway accepts no liability for proper coding by professional providers for tests ordered for their patients. Please talk to your billing code specialist or third party payer for specific guidance.

 


 

Billing_cpt-icon-72x68

CPT codes are five digit numeric codes that are used to describe a medical, laboratory, etc. services provided by physicians, hospitals, laboratories, and other health care entities and are used for reimbursement purposes. These codes are used to reflect the actual service or procedure that is being performed, and are maintained and copyrighted by the American Medical Association. Pathway Genomics accepts no liability for proper coding by professional providers for tests ordered for their patients. Please talk to your billing code specialist or third party payer for specific guidance.

Contact us for any additional questions:

Billing Department

Billing Department

(877) 559-1590

(858) 866-9751

billing@pathway.com

Client Services Department

Client Services Department

(858) 450-6600

(877) 505-7374

clientservices@pathway.com