What are the different categories of tests on HFHS Lab Formulary?

Unrestricted (Tier 1): These tests are available to all ordering providers and do not require any specific medical review. While the majority of Tier 1 tests are covered by insurance companies, ordering providers should be mindful for the medical efficacy for the need of the test and secure a pre-authorization, if required by insurance.

Restricted (Tier 2): These tests are limited to certain specialties and/or clinics. They are generally expensive and/or have very specific clinical utility. Hence, these tests are for use by ordering providers with domain expertize in a specific specialty area. In addition to selective ordering by a select group of providers, Tier 2 requests are subject to additional medical review by a laboratory based subject matter expert, usually a physician pathologist or a clinical scientist. The majority of Tier 2 tests are expensive and not/inadequately covered by insurance companies. Ordering providers are strongly advised to consider the medical efficacy of Tier 2 tests and secure prior-authorization before a sample is collected.

NOTE: Tier 1 and 2 laboratory tests are considered 'On Formulary' and the HFH Laboratory Service Line will assume the financial risk and perform the test or send out the sample to an external laboratory. Any external results from Tier 1 and 2 will be reported in the 'Lab Result' section of the electronic medical record.

Unavailable/Off-Formulary (Tier 3): These tests are not an available services through HFHS Laboratory Service Line and are comprised of tests that are either (a) new tests that have not yet been reviewed and categorized by MLFC (b) tests that were reviewed but failed to fulfill all criteria for inclusion in Lab Formulary (e.g. emerging tests that lack an extensive evidence base or have insurmountable proprietary or reimbursement complexity).

What is the workflow to access Unavailable/Off-Formulary (Tier 3) testing?

The ordering provider's clinic will be responsible for sample collection, shipping, and securing prior authorization if required. The ordering provider should request that the results will be sent directly to him/her and the clinic should scan them into the electronic medical record. Billing will be between the performing lab and patient/patient's insurance or clinic. HFHS Laboratory Service Line will not accept responsibility for payment or reporting of Off-Formulary Tests.

NOTE: Patient must sign the "Patient Information & Responsibility" Form. Scan a copy into the patient chart. Since ordering clinic will ship specimen to desired external laboratory, please include a copy of the "Patient Information & Responsibility Form" with the sample. If the specimen being sent for testing is a Histology Block, please also include Patient Information Release for Histology Blocks form.