All PlansPrior AuthMedium impact
22-496m 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
Prior authorization is no longer required for biomarker testing for patients with advanced or metastatic stage 3 or 4 cancer, or cancer progression/recurrence. Providers must bill applicable cancer diagnosis codes (C00-C96.Z) or history of cancer codes (Z85-Z85.9) in the primary position on claims.
Action Required
Immediately: Update billing system to remove prior authorization requirements for biomarker testing when primary diagnosis is cancer (C00-C96.Z) or history of cancer (Z85-Z85.9) for stage 3 or 4 cases. Train billing team to ensure cancer diagnosis codes are placed in primary position on all biomarker testing claims. Update encounter forms to remind providers of proper diagnosis code placement.