Genetic Testing Step 1 of 3 33% Member InformationEnter Member Id and Date of Birth to validate Member before proceeding with the form.Member's ID#* Member's DOB* MM slash DD slash YYYY Date of Service (if known) MM slash DD slash YYYY Name* First Last Error Message Provider InformationNPI of provider billing for services* Name of provider billing for services* Error Message MD requesting test* Phone #*Fax #*Contact Name* Email address in order to receive confirmation of request receipt* Clinical InformationThe test must be for the benefit of the member in that the test results will have an impact on and make a change in the member’s clinical management. The sensitivity of the test must be greater than the clinical pre-test probability of the diagnosis.CPT Code(s) (Click + or - at the right to add additional CPT Codes)*CPT CodeUnits Example CPT code: 12345Diagnosis (Click + or - at the right to add additional Diagnoses)*DiagnosisICD 10 Diagnosis Code Example ICD 10 Diag Code: Z87.890Medical NecessityIs the requested test for a specific genetic defect, such as Fragile X, or is it a screening test, such as the microarray? Please describe.*If the test is positive, how will that affect the member’s clinical management?*If the test is negative, how will that affect the member’s clinical management?*Is Test FDA Approved?*Is Test FDA Approved? *YesNoName of Genetic Test* Attach Clinical* Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 10 MB, Max. files: 10. Upload only PDF or Word DocumentSignature of Treating Physician*Signature Date:* Request Method*Request Method *StandardExpedited: By checking Expedited, you are stating that processing this request in the standard time (14 days) for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function. Please attach documentation that supports the need for an Expedited decision. Also please note that a request with a date of service in the past cannot be considered as Expedited.Attach additional Clinical documents for Expedited request*Accepted file types: pdf, doc, docx, Max. file size: 13 MB.Upload only PDF or Word DocumentsSignature of Physician or Licensed Provider (Required for Expedited request)*Signature Date:* CommentsAuthorization is not a guarantee of paymentCAPTCHA