6. Commercial Payer Programs

Palmetto GBA, LLC is the owner/licensor of the DEX® Diagnostics Exchange and DEX Diagnostics Exchange Registry software that includes the DEX Z-Codes and clinical content comprising information about laboratory tests for molecular diagnostics.

Palmetto GBA completes the Technical Assessment (TA) evaluation to determine if a test demonstrates clinical utility (CU) and meets analytical and clinical validity (AV/CV) criteria. Palmetto GBA does not provide coverage decisions for commercial health plans.

Yes, private commercial payers may also utilize the DEX Registry and related services, and you will be notified by your commercial payer with instructions if Z-Code requirements apply to your billed services.

The MolDX Program (Administered by Palmetto GBA) is a separate program specific to certain Medicare jurisdictions.

The same Z-Code can be used for both the Medicare and commercial health plans; however, the Technical Assessment (TA) result may differ.

If you previously registered in DEX and already have an active Z-Code for your test, then you do not need to add the test again. However, the test may now require additional TA documentation to be submitted for the Non-Medicare TA Evaluation. If the test has been identified by our system as requiring TA documentation for the Non-Medicare TA Evaluation, you will receive an email notification. If you have questions about whether you will be required to submit additional TA documentation for your test, please Contact Us.

The TA result is the determination resulting from the test review process performed by Palmetto GBA. In order for a Technical Assessment (TA) result to be Successful, the test will need to demonstrate it meets analytical validity (AV), clinical validity (CV), and clinical utility (CU) as outlined in Palmetto GBA established procedure or policy (based on evidentiary review).

Palmetto GBA does not provide coverage decisions for commercial health plans and the Technical Assessment result does not infer coverage.

Depending on the intended use of the test, more than one TA result may be rendered. If the use of the test does not differ in Medicare and Non-Medicare utilization, only a Medicare Evaluation or MolDX Program result will be seen (depending on jurisdiction). This does not imply the services are intended for Medicare payers but that the result for the Medicare and Non-Medicare TA is the same.

If the commercial TA procedure differs from Medicare based on the intended use of the test, a Non-Medicare TA Evaluation result may be populated for the test.

NOTE: Not all tests will have a Non-Medicare TA performed when the intended uses from Medicare and Non-Medicare are distinct because the service might not have an evaluation procedure in place yet. Non-Medicare TA relies on Palmetto GBA creating a process for performing such a test. If the test type is determined to be part of a future phased rollout, you will be notified on next steps for the TA process. Tests with a Non-Medicare TA result of ‘N/A’ may be part of these future phased rollouts.

No, commercial health plans coverage determinations are not available in the DEX Registry at this time. However, the test may be updated with a Technical Assessment (TA) result completed by Palmetto GBA.

Any Coverage result displayed under the MolDX Program is relevant for Medicare services within MolDX jurisdictions only.

For coverage questions, please contact your payer directly.