Children's Special Health Services

Genetic Testing Financial Assistance funds can be used when:

• The applicant’s insurance company will not pay for the test, or the applicant is uninsured or underinsured.
• The applicant has no other resource to cover the requested service.

Funds are limited and may not meet the needs of all individuals who qualify. The fund operates on a state fiscal year. New funds will be available every July 1^st. If the application is approved, the test must be completed before June 30th; otherwise, a new application will be required.

Shodair Children’s Hospital reviews applications for financial assistance with genetic testing. The review is based on the following information, which must be specific to the applicant, documented on the application, or submitted with the application:

• Pre- and post-test genetic counseling must be provided.
• A CLIA-certified laboratory must perform the requested test.
• Genetic testing is recommended to confirm or rule out a clinical diagnosis.
• The requested test is not considered experimental or investigational.
• The requested laboratory test is intended to provide clinical benefit (which may alter the course of treatment) to the patient.
• Current signs or symptoms or a family history suggest a genetic condition;
• Current medical records (applicant must have been seen within the last six months) and physician notes verify the confirmed or suspected medical condition for which testing is being planned.

The Genetic Financial Assistance Application can be found by clicking here.

In addition to the application, the provider requesting the laboratory testing must supply the following information:

• Current medical records and physician notes that detail the confirmed or suspected medical condition.
• If the individual has insurance coverage, you will need to pre-authorize the requested service and supply a copy of the determination.
• Include a copy of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services program denial letter if the individual is a child through age 20 and is covered under Medicaid or Healthy Montana Kids Plus. See the section below on special instructions for youth with Montana Medicaid Coverage.

If the applicant is a child under the age of 20 and is covered by Medicaid or Healthy Montana Kids Plus, follow the same process as when submitting claims and requesting prior authorizations, as outlined in the General Information for Providers Manual located at http://medicaidprovider.mt.gov.

If the requested procedure code is denied and/or not listed on the current fee schedule (located at the link above), you must request a review for medical necessity through the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program.

Contact the EPSDT Program Officer at (406) 444-0950 and ask for a Request for Additional Services (EPSDT) Information Sheet form. Complete and return the form to the EPSDT Program Officer. When the review is complete, the Program Officer will send a written approval or denial letter. If approved, the letter will contain instructions explaining where to send the claim or the Prior Authorization (PA) number (if necessary). If the test is denied, please continue with the Genetic Testing Financial Assistance application process.

General Inquiries: Don’t hesitate to get in touch with the Children’s Special Health Services’ Nurse Consultant at 406-444-3657 or email at chelsea.pugh@mt.gov.

Application-Specific Inquiries: If you have questions about a specific application, review timeline, or application requirements, please don't hesitate to contact Jaclyn Haven at Shodair Children’s Hospital at 406-444-7520 or via email at jhaven@shodair.org.