Tissue of Origin Test is covered by Medicare

Pathwork Diagnostics, Inc., is covered by Medicare. Palmetto GBA, the contractor that administers Medicare in California, has issued a positive coverage policy for the Pathwork® Tissue of Origin Test. Because all Tissue of Origin Test specimens are processed in the Pathwork Diagnostics Laboratory in California, the Palmetto decision means that the test will be covered for Medicare patients across the nation. The Tissue of Origin Test helps identify the primary tumor in difficult to diagnose cancer cases such as those that are metastatic or with a complex clinical history.

The Pathwork Tissue of Origin Test is the only FDA-cleared molecular diagnostic test for tissue of origin. It is now covered under Medicare. The information below can be downloaded here.

Patient Billing Programs

The Pathwork Tissue of Origin Test is advanced technology, and most insurance companies have not yet established a formal coverage policy. Pathwork Diagnostics wants to ensure that all patients will have access to the Tissue of Origin Test if their doctors believe it is medically necessary. To that end, Pathwork offers several programs addressing the needs of both insured and uninsured patients.

Through the toll free number (1.877.808.0006, prompt 5), Pathwork Reimbursement Assistance Program counselors can provide assistance to patients at any time in the billing process. The Pathwork counselor can also assist with billing questions, prior authorizations, appeals, financial assistance, and payment planning.

Policy Highlights

Medicare Patients
Once Pathwork has obtained the insurance information as part of the Requisition Form, Pathwork takes assignment for the claim and will bill Medicare for the test on behalf of the patient.

If Medicare denies a claim, Pathwork will not bill the patient for any balance.

Based on Medicare regulations, if the Tissue of Origin Test is ordered within 14 days of discharge, Pathwork must bill the hospital. It is the hospital’s responsibility to submit the claim to their local Medicare contractor.

Commercially Insured and Medicaid Patients
Once Pathwork has obtained the insurance information as part of the Requisition Form, Pathwork takes assignment for the claim and will bill the insurance company for the test on behalf of the patient.

If a commercial payer denies a claim, Pathwork will represent the patient in all internal levels of appeal, including an independent medical review if available. This process may require support from the ordering physician and patient. If Medicaid denies a claim, Pathwork will not bill the patient for any balance.

If the appeal process is exhausted, patients will remain responsible for their share of non-covered cost, i.e., insurance co-pay, deductibles and amounts in excess of coverage limits.

Pathwork offers generous financial assistance programs for those patients who qualify and whose insurance does not cover all or part of the cost of this test. Pathwork’s reimbursement assistance programs are described below and are available not only to patients of limited means, but to any patient for whom their physician believes the test is medically necessary.