Tricare DENIES Oncotype Test...any help?

I know when I got my onco test done, I was told if my insurance would not cove it that Genomic health had a program that could help pay for the cost of the test. Thankfully my insurance paid. I would call Genomic and ask.

Ladies - I am also Tricare Prime.  Anything that Tricare Prime is being requested to cover requires a referral first to determine whether they will cover the service.  Many services you receive as a patient require you to sign a personal responsibility statement, indicating you will be liable to pay whatever insurance has not paid.  My BS ordered a Mammaprint test at the time of my biopsy.  His office did not get a referral from Tricare Prime for this test.  Tricare considers this test experimental and would not pay Agendia the test cost, even though it is FDA approved.  This is a genetic assay, and was the first indicator of hormone receptor status and Her2Neu status. I had received a letter from Tricare showing the denial and appeal. Tricare did pay a small portion of the $5,000 bill, I believe about $61.00.  I called Agendia and asked for an AOB form to be faxed to my home.  It is a form that indicated Agendia would accept whatever insurance paid.  I already knew that Tricare had paid the $61.00, and I knew that I had not been consulted about the order for the test, and had not signed anything saying I would be responsible for the bill if insurance did not pay.  Agendia had to absorb the remainder of the bill after I faxed the AOB (Assignment of Benefits) form back to them.  I also contacted my BS office to let them know of the situation.  I just looked at the Genomics website, and based on what I read there it looks like if you have Tricare Prime and they require a referral before testing is done, it was your provider's responsibility to obtain that referral before ordering the test. Your provider should be on the hook if you didn't sign anything saying you would be responsible for any costs not covered by insurance. They are the ones who ordered the test, not you, and submitted the sample for testing without prior authorization.

For those that have had testing done (Oncotype) that has been denied, but know someone who has had Oncotype successfully paid for at 86%, I would inquire about the billing code used to get that payment.  I don't know why there would be inconsistency in payment by Tricare unless an incorrect billing code was used, the claim denied, and then the same code submitted again, denied again, etc.  My assumption is that Tricare either covers the test or not, but I am also wondering if denial has to do with being ER+ and node positive, since Oncotype is advertised for ER+ and node negative patients.

Perhaps Tricare pays for the test only if you are node negative, or premeno, or postmeno, or ???

I don't have Tricare but was told by Genomic that it wasn't a covered benefit for me & that they would appeal for coverage. They did & got coverage, all but about $175 dollars which Genomic excepted as full paymnet. I think the reason my insurance company didn't want to pay was because I was premeno & had positive nodes(not a lot of data, yet). Good Luck.

ALittle Bit British - so sorry to hear of your ER visit and cellulitis!  Never fun!  Hope it (and your Oncotype bill) are resolved soon!

Hi Tori:

I am not on Tricare but had trouble and received a HUGE bill from Genomic after my OncoDX testing as well.  It turned out to be problems because they billed it wrong to my insurance.  Then when they did it right, and the insurance paid, they still did something else wrong because the insurance sent US the check and then we had to send it to them!  Then they caught the error and billed insurance again and they paid them direct (so they had 2 payments) and insurance wanted money back from us!!!  Of course we didn't have it to send!  It took about 2 months and the help of my insurance rep to get it all straightened out.

Genomic definitly needs improvement in their billing departments.  They are either not competent or very under-staffed! 

Don't give up and work with your mlitary rep to get assistance and get it figured out.