Coverage and Billing Guidance for Biomarker Testing
Date: 01/26/26
Sunshine Health covers biomarker testing in alignment with the Agency for Health Care Administration (AHCA) policy.
AHCA updated the Medicaid Laboratory Services Coverage Policy to include coverage of biomarker testing effective June 1, 2025.
Biomarker tests require prior authorization and are reviewed for medical necessity.
The Practitioner Laboratory Fee Schedule added 632 biomarker test codes with pricing information effective July 1, 2025. The January 1, 2026, Medicaid fee schedule will cover additional codes for a total of 941 biomarker test codes, per AHCA.
What Are Biomarker Tests?
Laboratory tests samples of blood, tissue or other bodily fluids to check for certain genes, proteins or other molecules for the purposes of:
- Diagnosing a patient for a condition or disease
- Determining their risk of developing a condition or disease
- Determining how they may respond to treatment
- Managing their treatment
- After a diagnosis, determining the risk
Biomarker Codes
- CPT® Codes (Current Procedural Terminology): Common molecular and genetic tests
- PLA Codes (Proprietary Laboratory Analyses): A specific company’s lab tests
- MAAA Codes (Multianalyte Assays with Algorithmic Analyses): Multiple biomarkers run through a mathematical algorithm
Biomarker Resources
- AHCA Laboratory Services Coverage Policy (PDF)
- Sunshine Health: Genetic Testing Coverage and Lab Options
This Guidance Applies to These Products
- Sunshine Health Medicaid (MMA)
- Comprehensive Long Term Care (LTC)
- Sunshine Health Pathway to Shine Child Welfare Specialty Plan (CWSP)
- Sunshine Health Mindful Pathways Serious Mental Illness Specialty Plan (SMI)
- Sunshine Health Power to Thrive HIV/AIDS Specialty Plan (HIV)
Questions?
Sunshine Health has a wealth of resources available to help answer your questions and address your concerns:
- Provider Support: Finding the Right Contact
- Provider Services: Call 1-844-477-8313
- Secure Provider Portal: Visit the Secure Provider Portal to check member eligibility, submit claims and more.
- Provider Engagement: Use the Find Your Account Manager tool to find the Provider Engagement Account Manager (PEAM) supporting your specialty and region.
- Claim Concerns: Resolve outstanding claims using the Claim Concerns form.
- Provider News: Bookmark Sunshine Health Provider News to keep up with the latest updates.
- Provider Newsflash: Subscribe to our e-newsletter to get regular updates.
- Provider Resources: Visit Manuals, Forms and Resources to find provider manuals, important forms, scheduling standards and other resources.
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