Supporting Your Patients
Exact Sciences believes that everyone should have access to the information they need to make confident, informed decisions about their cancer treatment.
Are you a patient? Go to Cost & Coverage for Patients
Genomic Access Program
To advance this mission, we created the Genomic Access Program (GAP) to help patients navigate and understand the insurance and billing process for the Precision Oncology portfolio of tests. GAP assists with obtaining prior authorizations, billing insurance, appealing denied claims and providing flexible payment options when necessary.
Insurance Coverage
The Oncotype® and OncoExTra™ tests are covered by Medicare and many commercial insurance plans and available to patients who are enrolled in a Medicaid program. Exact Sciences* is an in-network provider with many health plans, including Aetna, Anthem, Cigna, Humana and UnitedHealthcare. Exact Sciences performs the services ordered and deemed medically necessary, regardless of network-provider status.
Financial Assistance Estimator
See if your patient could be eligible for testing at no cost with the Financial Assistance Estimator.
Complete the following fields and hit submit.
Patient Qualification:
Qualify for financial assistance
Based upon the information provided you could have no out-of-pocket costs for this test.
Please note that additional information is required to apply:
1
Download the
Download application in Spanish
2
Complete and submit the form along with required supporting documentation
3
Exact Sciences will review your completed application and confirm eligibility
Patient Qualification:
Do not qualify for financial assistance
Based upon the information provided, the financial assistance criteria have not been met.
However, Exact Sciences offers flexible payment options and can discuss any extenuating circumstances the patient may have.
Contact Customer Service at 888-ONCOTYPE (888-662-6897), option 2 to discuss further.
Genomic Access Program
It starts with you…and we take it from there
1You order an Oncotype or OncoExTra test
Ordering a Test
Ordering a test and receiving the results is a straightforward process.
Online Ordering
For faster results, complete your requisition form online on the Provider Portal
Necessary Information
Be sure to include a copy of your patient’s insurance card and the primary ICD-10 code selection supporting medical necessity. When ordering for your Medicare patients, please include the Specimen Collection Date and Patient Hospital Status to streamline the process.
2We verify and bill insurance
Verify & Bill Insurance
The billing process starts with performing insurance verification for each patient using the insurance information provided when the test is ordered.
Prior Authorizations
We obtain prior authorizations, when required by the payer, using the documentation provided by your office on the completed requisition form. The insurance information you provide helps us determine whether prior authorization or other forms are required by the insurance company. We will contact your office with instructions if the payer requires that the physician initiate the Prior Authorization or asks for additional documentation from your office.
Explanation of Benefits
Once testing is complete, we handle insurance billing on behalf of your patients when this option is selected on the requisition form. Patients may receive one or more Explanation of Benefits (EOB) from their insurance company. Even though this is not a bill, we are here to answer any questions patients may have.
3We offer financial assistance
Assistance with Appeals
If the claim is denied, we will pursue appeals on the patient’s behalf if appeal options are available. This process can take several months.
Out-of-Pocket Payment Options
Out-of-pocket (OOP) costs for the test, if any, are determined by the insurance company. Patients may have financial responsibility for a co-pay, co-insurance, deductible or non-covered charges as determined by their insurance plan once available appeal options are completed. If your patient’s out-of-pocket amount exceeds $500, they will receive a call to discuss payment options. We will also submit secondary or supplemental insurance claims on your patient’s behalf if the necessary information was submitted with the order. If your patient receives a bill and is not sure if a claim was submitted to their secondary or supplemental insurance, please have your patient contact us.
Financial Assistance
Financial assistance is available for eligible patients who are uninsured and may be available for insured patients unable to pay the out-of-pocket amount determined by their insurance.
- Eligibility is based on Federal poverty guidelines, and we proactively contact all uninsured patients to determine eligibility for financial assistance. Payment plans may also be available.
- Patients may also contact us before the test is ordered or during the testing process to review available payment terms or to be pre-screened† for financial assistance.
- Financial assistance is not available if a patient has insurance coverage but elects to be billed directly instead of billing insurance.
Because insurance coverage varies across the country and is based on medical policy and benefit design, it is sometimes difficult for patients to understand costs associated with testing. We strongly encourage patients to contact their insurer when they have questions about their plan design and benefits.
Medicare Information
Oncotype and OncoExTra tests are covered by Medicare Fee for Service (FFS) for patients meeting coverage criteria. Patients who meet clinical criteria for coverage have zero financial responsibility.
See the specific coverage criteria for each test
Advance Beneficiary Notice (ABN) Requirements
Medicare FFS requires that providers give their Medicare patients an ABN form before they receive any services not considered medically necessary under the Medicare FFS program. This is required because the patient will be responsible for paying for the test if they still choose to receive it.
The 14-Day Rule
Medicare FFS has specific date of service reporting requirements for laboratory tests, and the technical component of physician pathology services, ordered for Medicare patients (commonly known as the “14-Day Rule”). The 14-Day Rule determines whether the laboratory performing the test bills Medicare directly or bills the hospital where the specimen was collected.
In general, Medicare requires that laboratories bill the hospital when the test is ordered less than 14 days following a patient’s inpatient or outpatient hospital stay (when the specimen was collected). However, as of January 1, 2018, the 14-day rule does not apply to molecular pathology tests when the specimen is collected from a hospital outpatient, regardless of order date.
We process test orders as they are received from providers. Clinical judgment should be the determining factor for test ordering.
Resources
Helpful documents to download
Download in other languages: Spanish | Traditional Chinese | Simplified Chinese
-
Footnotes
Medicare Coverage Criteria for Each Test
-
Oncotype DX Breast DCIS Score Assay
-
Oncotype DX Breast Recurrence Score Assay
-
Oncotype DX Colon Recurrence Score Assay
-
OncoExTra
Local Coverage Determination (LCD): MolDX: Oncotype DX Breast DCIS Score Assay (Genomic Health) (L36941)
The Oncotype DX Breast DCIS Score assay is covered only when the following clinical conditions are met:
- Pathology (excisional or core biopsy) reveals ductal carcinoma in situ of the BREAST (no pathological evidence of invasive disease), and
- FFPE specimen with at least 0.5 mm of DCIS length, and
- Patient is a candidate for and is considering BREAST conserving surgery alone as well as BREAST conserving surgery combined with adjuvant radiation therapy, and
- Test result will be used to determine treatment choice between surgery alone vs. surgery with radiation therapy, and
- Patient has not received and is not planning on receiving a mastectomy.
Local Coverage Article: Billing and Coding: MolDX: Oncotype DX Breast Recurrence Score Cancer Assay (A54480)
Oncotype DX Breast Recurrence Score test was developed for patients with the following findings:
- Estrogen receptor-positive, node-negative carcinoma of the BREAST
- Estrogen receptor-positive micrometastases of carcinoma of the BREAST, and
- Estrogen receptor-positive BREAST carcinoma with 1-3 positive nodes
Local Coverage Article: Billing and Coding: MolDX: Oncotype DX Colon Recurrence Score Assay (A54484)
The Oncotype DX Colon Recurrence Score test, developed to predict the recurrence risk for patients with Stage II COLON CANCER.
Local Coverage Determination (LCD): MolDX: Next-Generation Sequencing for Solid Tumors (L38045)
Coverage Indications, Limitations, and/or Medical Necessity
This policy describes and clarifies coverage for Lab-Developed Tests (LDTs), Food and Drug Administration (FDA)-cleared, and FDA-approved clinical laboratory tests utilizing Next-Generation Sequencing (NGS) in cancer as allowable under the National Coverage Determination (NCD) 90.2, under section D describing Medicare Administrative Contractor (MAC) discretion for coverage. This policy’s scope is specific for solid tumor testing, and is exclusive of hematologic malignancies, circulating tumor DNA testing (ctDNA), and other cancer-related uses of NGS, such as germline testing in/for patients with cancer.
All the following must be present for coverage eligibility:
- As per NCD 90.2, this test is reasonable and necessary when:
- the patient has either:
- Recurrent cancer
- Relapsed cancer
- Refractory cancer
- Metastatic cancer
- Advanced cancer (stages III or IV)
AND has not been previously tested by the same test for the same genetic content
AND is seeking further treatment
Have a specific billing question?
Contact us to learn more about billing and coverage for our tests.