Mammoprint....Help......insurance not paying

Have you tried contacting the BS's office that told you not to worry about it?

Your physician should have gotten a prior authorization for the test before scheduling it. At the very least the facility that performed the test should have had it prior auth'd. If they didn't do that, they should be liable for it, not you.

My insurance did not cover Mammaprint in 2010, denying due to regarding it as '"experimental" even though it was FDA approved at the time. My insurance did pay for the shipping charge to send the sample to Agendia Labs. I called Agendia and asked for an AOB (Assignment of Benefits) form which states they will accept whatever insurance pays. I signed it and faxed it back, and that shipping charge of $61 is all they got. If you did not sign any forms saying you accept responsibility for payment should insurance not cover this test, it was incumbent upon either your BS office, or Agendia, to determine financial responsibility before the test was run. I would call BCBS and ask if they cover the test under any circumstances, or only certain ones. Depending on their response, I would ask your BS why he chose this test over Oncotype Dx, which is more routinely covered. I would ask the BS to do a peer to peer review with BCBS if they indicate they cover the test under certain circumstances

mysunshine, I agree with SpecialK. Call BCBS and ask them about the claim status. If they inform you that the claim denied, ask them to let you know the reason for the denial. You usually have 180 days from the date of claim denial to file a grievance and appeal. Ask the representative if you are still within timely filing. This test is covered for medical necessity if certain conditions apply. Please see the following guidelines under the following link: https://www.anthem.com/ca/medicalpolicies/policies/mp_pw_a049879.htm. Blue Cross Blue Shield = Anthem, same guidelines should apply. The ordering MD and or the rendering facility is usually responsible for obtaining precertifcation, but it all depends on the employers evidence of coverage at the time services were rendered. Some contracts state "members responsibility to obtain authorization". Please don't go by what the doctors office tells you as they cannot have the charges written off, if the charges are from a third party vendor (Agendia). Hope this helps.

I am in the same boat. It's Agendia, and they have not had a contract with BCBS since 2012, so I think our doctors would have gotten the message by now. I have been calling my doctor's office to try to get a statement of medical necessity so I can send an appeal to the insurance. So far, no calls back. Guess I will have to go over there and camp out.

Has anyone negotiated a payment with Agendia? I know I didn't sign anything specific to this test, but would the blanket form I signed before surgery cover this? I was also informed about the test after it had been ordered.

Finally heard from the office manager at my surgeon's office. According to her, Agendia should have contacted me before they did the test to make sure I knew it was not covered. So, she was going to call them. My surgeon's office is now ordering Oncotype DX, and this is how they operate. Since they aren't ordering tests from Agendia any more not sure how much leverage they will have.

I can tell you that the Oncotype test is half as much as the Mammaprint! Turns out I got both, my Oncologist didn't like the Mammaprint test. BCBS paid the cheaper one.

Will come back and post when I hear anything else. If I get billed by Agendia will ask what their uninsured rate is.