CommercialPrior AuthMedium impact
22-495m Cancer Patients Can Now Get Better Access to Biomarker Testing
Health Net·CA · Oncology, Hematology·Prior Authorization
Effective date
Jul 1, 2022
We identified it
Jun 20, 2026
Summary
Health Net has eliminated prior authorization requirements for biomarker testing in patients with advanced or metastatic stage 3 or 4 cancer, effective July 1, 2022. Providers must bill cancer diagnosis codes (C00-C96.Z) or history of cancer codes (Z85-Z85.9) in the primary position on claims for this testing.
Action Required
Immediately: Billing team must update prior authorization workflows to remove authorization requirements for biomarker testing when patients have advanced/metastatic stage 3 or 4 cancer diagnosis codes. Ensure cancer diagnosis codes (C00-C96.Z) or history of cancer codes (Z85-Z85.9) are billed in primary position on all biomarker testing claims. Update billing system rules and train staff on new workflow.