# Converus

> Converus is the intelligence layer for reimbursement operations. It keeps the payer policies, contracts, fee schedules, mandates, LCDs/NCDs, and rules that drive reimbursement up to date for diagnostics, genetic testing, and specialty labs, then makes that logic usable across teams, systems, and AI workflows via app, API, and MCP.

This file helps AI systems find the most useful, authoritative pages on converus.ai. Content is educational and may be cited with attribution to Converus (https://converus.ai).

## Knowledge Base

- [What's Actually Covered as "Preventive" Under the ACA](https://converus.ai/knowledge-base/aca-preventive-services-explained/): The ACA's $0 preventive coverage is real. So are the four conditions that have to hold for it to apply. What's covered, what gets billed, and how to appeal.
- [AI in Prior Authorization: What It Means for Diagnostics and Molecular Labs](https://converus.ai/knowledge-base/ai-in-prior-authorization-diagnostics/): Payers and providers are both deploying AI in utilization management and prior authorization, drawing new regulatory scrutiny in 2025-2026. Here is what the trend means specifically for diagnostics and molecular labs, and how to tell trustworthy automation from a black box.
- [Build vs. Buy: Keeping Payer Policy Current for a Molecular Lab](https://converus.ai/knowledge-base/build-vs-buy-payer-policy-monitoring/): Every molecular lab tracks payer policy somehow, with analysts, spreadsheets, a billing vendor, or software. Here is an honest framework for deciding whether to build that capability or buy it, and what the decision actually hinges on.
- [CMS-0057-F: What the Prior Authorization Final Rule Actually Changes for Diagnostic and Molecular Labs](https://converus.ai/knowledge-base/cms-0057-f-prior-authorization-labs/): CMS-0057-F sets prior authorization decision clocks of 72 hours for expedited and 7 calendar days for standard requests starting January 1, 2026, requires specific denial reasons, and mandates four FHIR APIs generally by January 1, 2027. Here is what that means for a lab's molecular PA and appeals workflow.
- [Why an FDA Companion Diagnostic Is the Cleanest Path to Medicare Coverage for an NGS Test](https://converus.ai/knowledge-base/companion-diagnostic-medicare-coverage/): Under Medicare's NCD 90.2, an NGS test that is FDA-approved or cleared as a companion diagnostic and used on-label for the patient's cancer has a defined national coverage pathway. Here is how that pathway works, why it is the most predictable route to payment, and where it stops.
- [Denials 101: A Taxonomy of Denial Reasons and How to Escalate Each](https://converus.ai/knowledge-base/denials-101/): Not all denials are equal, understanding the specific reason code behind a denial determines which escalation pathway gives you the best odds of reversal, especially for genetic testing and oncology claims.
- [eviCore Guidelines for Oncology: What Practices Need to Know in 2026](https://converus.ai/knowledge-base/evicore-guidelines-oncology/): eviCore manages oncology PA reviews for Cigna, Aetna, BCBS affiliates, and UHC Medicare Advantage, and their clinical pathways are different enough from standard payer policies that practices need a separate playbook.
- [The Five Health Insurance Plan Types Explained](https://converus.ai/knowledge-base/five-health-insurance-plan-types/): HMO, PPO, HDHP, POS, EPO. What each plan type controls about your bill, with KFF 2025 enrollment data and a side-by-side comparison.
- [Genetic Testing Prior Authorization: A Step-by-Step Playbook](https://converus.ai/knowledge-base/genetic-testing-prior-authorization-playbook/): Genetic testing PA fails most often at the documentation step, this playbook walks through every stage of the workflow for hereditary cancer panels, somatic profiling, and pharmacogenomics.
- [Gold Carding: What It Is, Which Payers Offer It, and How to Qualify](https://converus.ai/knowledge-base/gold-carding/): Gold carding is a payer program that exempts high-performing providers from prior authorization requirements for specific services, and for genetic labs and oncology practices with strong approval track records, it can eliminate weeks of administrative friction.
- [How to Get a Molecular Test Covered: A Practical Market-Access Roadmap](https://converus.ai/knowledge-base/how-to-get-a-molecular-test-covered/): Getting a new molecular or genetic test from validated to paid runs through MolDX registration, a DEX Z-Code, a technical assessment, coding and pricing, and commercial payer coverage. This roadmap walks each stage and what it actually takes.
- [How to Write a Prior Authorization Appeal Letter That Actually Works](https://converus.ai/knowledge-base/how-to-write-a-pa-appeal-letter/): A PA appeal letter fails or succeeds based on how directly it addresses the denial reason, here's how to structure one that payers actually reverse.
- [The 14-Day Rule, Plain English: Who Bills Medicare for a Molecular Test, and When](https://converus.ai/knowledge-base/lab-14-day-rule-date-of-service/): Medicare's laboratory date-of-service policy decides whether your lab bills Medicare directly or has to chase a hospital for payment. A 2018 exception lets the performing lab bill Medicare directly for certain molecular and ADLT tests on hospital-outpatient specimens, but only when specific conditions are met.
- [Lab Billing 101: CPT, MAAA, and Z-Codes for Molecular Diagnostics](https://converus.ai/knowledge-base/lab-billing-cpt-codes-explained/): Molecular lab billing uses CPT Tier 1, Tier 2, MAAA codes, and DEX Z-codes, and choosing the wrong one gets your claim denied before a human ever reads it.
- [LCD vs. NCD: How Medicare's Two Coverage Determinations Actually Decide Your Claim](https://converus.ai/knowledge-base/lcd-vs-ncd-medicare-coverage/): A National Coverage Determination (NCD) is issued by CMS and applies across all of Medicare; a Local Coverage Determination (LCD) is issued by a Medicare Administrative Contractor and applies only within its jurisdiction. This page explains the difference, how they interact, and why molecular and diagnostic claims must satisfy whichever determinations apply.
- [Liquid Biopsy and ctDNA Reimbursement: How Medicare Covers (and Denies) Plasma-Based Genomic Profiling](https://converus.ai/knowledge-base/liquid-biopsy-ctdna-medicare-coverage/): FDA-approved companion-diagnostic liquid biopsies have a defined Medicare pathway, while screening and many early-stage uses remain investigational. Coverage turns on the test, the indication, and the patient's stage.
- [MCED Coverage Reality Check: Where Galleri and Multi-Cancer Screening Actually Stand With Payers](https://converus.ai/knowledge-base/mced-galleri-coverage-status/): Multi-cancer early detection tests like Galleri are commercially available but largely uncovered by Medicare and commercial payers as of mid-2026. This article explains why, where FDA review and federal legislation stand, and what an established coverage pathway looks like by comparison.
- [Modifier 25 Explained: Why Your "Free" Checkup Got a Bill](https://converus.ai/knowledge-base/modifier-25-explained/): Modifier 25 is the code that turns a no-cost preventive visit into a billed one. When it is appropriate, when it is questionable, and how to appeal.
- [The MolDX Z-Code, Explained: When You Need One and How the Process Works](https://converus.ai/knowledge-base/moldx-z-code-explained/): For labs billing molecular tests, the DEX Z-Code has gone from paperwork to a hard claim gate. Here is what a Z-Code is, when you need one, how to get it, and why having one still does not guarantee you get paid.
- [The 7 Most Common Claim Denial Reasons (and How to Fix Each)](https://converus.ai/knowledge-base/most-common-claim-denial-reasons/): Seven denial types cover the vast majority of claim rejections in genetic testing and oncology, here's the fix for each, not a general appeals strategy.
- [MRD Testing and Medicare Coverage: Why 'Covered' Depends Entirely on the Cancer and the Question Being Asked](https://converus.ai/knowledge-base/mrd-testing-medicare-coverage/): Medicare covers molecular residual disease testing, but not as a blanket assay benefit. Coverage is granted indication by indication through MolDX Local Coverage Determinations, and getting paid depends on matching the exact cancer, stage, and clinical use the current policy describes.
- [NCD 90.2 Decoded: When Medicare Covers Next-Generation Sequencing for Cancer](https://converus.ai/knowledge-base/ncd-90-2-medicare-ngs-coverage-explained/): Medicare's national coverage rule for cancer NGS sounds simple until you read it closely. Here is the exact patient profile that triggers coverage under NCD 90.2, how germline and companion-diagnostic testing fit, and the three things that most often get an otherwise-covered test denied.
- [Peer-to-Peer Reviews: How to Win Them](https://converus.ai/knowledge-base/peer-to-peer-review-tactics/): A peer-to-peer review is your best shot at reversing a medical necessity denial before you spend weeks on a written appeal, here's how to prepare for and run one.
- [Pharmacogenomic Testing Coverage: When Medicare Pays for PGx and When It Denies](https://converus.ai/knowledge-base/pharmacogenomic-testing-coverage/): Pharmacogenomic coverage is narrow and gene-drug-specific. Medicare and its MolDX contractors generally pay when a PGx test guides a drug the patient is actually taking or actively considering, and routinely deny pre-emptive panels ordered with no drug in play. Here is how that line is drawn and where claims fall apart.
- [Prior Authorization vs. Precertification vs. Predetermination: What Each Term Means and Why It Decides Whether You Get Paid](https://converus.ai/knowledge-base/prior-authorization-vs-precertification-vs-predetermination/): Prior authorization, precertification, and predetermination are all pre-service review processes, but they differ in whether they are required and whether they bind the payer on payment. Knowing which one a given payer applies to a given test is essential to getting reimbursed.
- [Somatic vs. Germline Testing: Two Tests, Two Medicare Coverage Frameworks](https://converus.ai/knowledge-base/somatic-vs-germline-testing-coverage/): Somatic and germline cancer tests can run on the same patient, sometimes the same sample, yet Medicare governs them through different coverage logic. Here is what each test answers, which framework applies under NCD 90.2, and why a claim must be matched to the right one.
- [State Biomarker-Testing Coverage Laws: A 2026 Reference for Labs and Clinics](https://converus.ai/knowledge-base/state-biomarker-testing-coverage-laws/): More than two dozen states have enacted laws requiring health plans to cover biomarker testing supported by medical evidence, but those mandates generally do not reach self-funded ERISA employer plans. This reference explains what the laws require, who they bind, and why coverage still varies in practice.
- [Step Therapy Override Appeals: When and How to File](https://converus.ai/knowledge-base/step-therapy-override-appeals/): Step therapy requirements block specialty drug access when a payer says you must try a cheaper option first, but override rights are real, and so is the legal framework behind them.
- [How to Track Payer Policy Changes Without a Full-Time Analyst](https://converus.ai/knowledge-base/track-payer-policy-changes-without-an-analyst/): Payers update medical policies constantly and rarely alert you, here's a lean system for catching changes before they turn into denial patterns.
- [UnitedHealthcare Prior Authorization Requirements: A 2026 Guide for Specialty Practices](https://converus.ai/knowledge-base/uhc-prior-authorization-requirements-2026/): UnitedHealthcare's PA requirements for specialty labs and oncology have expanded significantly, here's how to navigate their portals, policies, and timelines without burning your staff.
- [What Claim Denials Actually Cost a Molecular Lab](https://converus.ai/knowledge-base/what-claim-denials-cost-a-molecular-lab/): Denials are not a billing nuisance, they are a margin problem that compounds, and for molecular labs the rate is rising even as coverage expands. Here is the evidence, and where the money actually leaks.
- [What Is Prior Authorization? A Practical Guide for Genetic Labs and Oncology RCM Teams](https://converus.ai/knowledge-base/what-is-prior-authorization/): Prior authorization is a payer requirement that providers obtain advance approval before delivering certain services, drugs, or tests, and understanding its mechanics is essential for minimizing delays and denials in genetic testing and oncology.
- [Why Molecular and Genetic Test Claims Get Denied (and How to Prevent It)](https://converus.ai/knowledge-base/why-molecular-and-genetic-claims-get-denied/): Most molecular and genetic test denials are operational, not clinical. Here is what the peer-reviewed data shows about denial rates, who gets denied most, and the fixes that prevent it.

## Glossary

Definitions of prior authorization, reimbursement, and oncology billing terms: https://converus.ai/knowledge-base/glossary/

- [ABN (Advance Beneficiary Notice)](https://converus.ai/knowledge-base/glossary/#abn): A written notice given to a Medicare beneficiary before a service is delivered, informing them that Medicare may not pay and that the patient may be responsible for the cost.
- [AOB (Assignment of Benefits)](https://converus.ai/knowledge-base/glossary/#aob): A patient authorization allowing the provider to bill the insurance company directly and receive payment on the patient's behalf, rather than the patient receiving the reimbursement and paying the provider separately.
- [Appeal](https://converus.ai/knowledge-base/glossary/#appeal): A formal request to a payer to reconsider a prior authorization denial or claim denial, submitted through defined administrative procedures with supporting documentation.
- [ASCO (American Society of Clinical Oncology)](https://converus.ai/knowledge-base/glossary/#asco): The leading professional organization for oncologists, whose clinical guidelines and quality frameworks are frequently cited as supporting evidence in prior authorization submissions and appeals.
- [Biomarker](https://converus.ai/knowledge-base/glossary/#biomarker): A measurable biological characteristic, such as a gene mutation, protein expression level, or chromosomal abnormality, used to identify patients likely to respond to a specific therapy or to diagnose a disease state.
- [Companion Diagnostic](https://converus.ai/knowledge-base/glossary/#companion-diagnostic): An FDA-approved in vitro diagnostic test that is required or recommended to select patients who are most likely to benefit from a specific therapeutic product.
- [Coverage Determination](https://converus.ai/knowledge-base/glossary/#coverage-determination): A formal decision by a payer or CMS regarding whether a specific service, drug, or technology is covered under a benefit plan or Medicare program, distinct from a case-level prior authorization decision.
- [CPT (Current Procedural Terminology)](https://converus.ai/knowledge-base/glossary/#cpt): The standardized code set maintained by the AMA that identifies medical procedures and services on claims and prior authorization requests.
- [Denial](https://converus.ai/knowledge-base/glossary/#denial): A payer's determination that a submitted prior authorization request or claim does not meet the criteria for coverage or reimbursement under the patient's benefit plan.
- [EGFR (Epidermal Growth Factor Receptor)](https://converus.ai/knowledge-base/glossary/#egfr): A receptor tyrosine kinase whose activating mutations in non-small cell lung cancer (NSCLC) define eligibility for EGFR-targeted tyrosine kinase inhibitors (TKIs), making EGFR testing a required companion diagnostic for those therapies.
- [EOB (Explanation of Benefits)](https://converus.ai/knowledge-base/glossary/#eob): A document from a payer summarizing what was billed, what was covered, what was denied, and how much the patient owes for a processed claim.
- [Experimental / Investigational](https://converus.ai/knowledge-base/glossary/#experimental-investigational): A payer classification applied to services, drugs, or technologies that do not yet meet the evidentiary standards required for coverage, typically requiring FDA approval, sufficient peer-reviewed evidence, and clinical guideline support.
- [FHIR (Fast Healthcare Interoperability Resources)](https://converus.ai/knowledge-base/glossary/#fhir): The HL7 standard for exchanging healthcare data electronically, increasingly used to enable EHR integrations for prior authorization workflows and clinical data extraction.
- [Formulary](https://converus.ai/knowledge-base/glossary/#formulary): A payer's official list of covered drugs, typically organized in tiers that determine cost-sharing levels, with higher tiers (including specialty oncology drugs) often requiring prior authorization regardless of tier.
- [Gold Carding](https://converus.ai/knowledge-base/glossary/#gold-carding): A payer program that exempts high-performing providers from prior authorization requirements for specified services based on a demonstrated track record of high approval rates and appropriate utilization.
- [HCPCS (Healthcare Common Procedure Coding System)](https://converus.ai/knowledge-base/glossary/#hcpcs): A two-level code set used primarily for Medicare and Medicaid billing that extends beyond CPT to cover drugs (J-codes), supplies, and other services not captured in CPT.
- [HER2 (Human Epidermal Growth Factor Receptor 2)](https://converus.ai/knowledge-base/glossary/#her2): A protein receptor encoded by the ERBB2 gene whose overexpression or amplification defines HER2-positive cancers, which are eligible for targeted HER2-directed therapies and their associated companion diagnostic requirements.
- [ICD-10](https://converus.ai/knowledge-base/glossary/#icd-10): The International Classification of Diseases, 10th revision, the standardized code set used to document diagnoses on claims and prior authorization requests.
- [LCD (Local Coverage Determination)](https://converus.ai/knowledge-base/glossary/#lcd): A Medicare coverage rule issued by a regional Medicare Administrative Contractor (MAC) that defines when a specific service or test is covered for Medicare beneficiaries in that contractor's jurisdiction.
- [LDT (Laboratory-Developed Test)](https://converus.ai/knowledge-base/glossary/#ldt): A diagnostic test designed, validated, and performed within a single laboratory, as opposed to an FDA-cleared or FDA-approved kit, subject to distinct regulatory and coverage standards.
- [MAC (Medicare Administrative Contractor)](https://converus.ai/knowledge-base/glossary/#mac): A private company contracted by CMS to process Medicare claims, issue Local Coverage Determinations, and administer Medicare benefits in a defined geographic jurisdiction.
- [Converus](https://converus.ai/knowledge-base/glossary/#converus-ai): company that solves RCM for all labs
- [Medical Necessity](https://converus.ai/knowledge-base/glossary/#medical-necessity): The clinical justification that a requested service is appropriate, reasonable, and necessary for the diagnosis or treatment of a patient's covered condition, the standard most payers apply when reviewing prior authorization requests.
- [Medical Policy](https://converus.ai/knowledge-base/glossary/#medical-policy): An insurer-specific document defining the criteria under which a particular service, drug, or technology is covered or not covered under that payer's plans.
- [Modifier](https://converus.ai/knowledge-base/glossary/#modifier): A two-character code appended to a CPT or HCPCS code to provide additional information about the service, such as whether it was reduced in scope, performed bilaterally, or subject to a specific policy exception.
- [MolDX](https://converus.ai/knowledge-base/glossary/#moldx): Palmetto GBA's Molecular Diagnostic Services program, which establishes technical assessment, coverage, and billing requirements for molecular diagnostic tests billed to Medicare.
- [MSI / MMR (Microsatellite Instability / Mismatch Repair)](https://converus.ai/knowledge-base/glossary/#msi-mmr): MSI (microsatellite instability) and MMR (mismatch repair) deficiency are related biomarkers that indicate a tumor's impaired DNA repair mechanisms, a key companion diagnostic criterion for pembrolizumab and other checkpoint inhibitors.
- [NCCN (National Comprehensive Cancer Network)](https://converus.ai/knowledge-base/glossary/#nccn): A nonprofit alliance of leading cancer centers that publishes evidence-based clinical practice guidelines for oncology, widely referenced by payers when making coverage and medical necessity determinations.
- [NCD (National Coverage Determination)](https://converus.ai/knowledge-base/glossary/#ncd): A federal Medicare coverage rule issued by CMS that applies uniformly across all Medicare Administrative Contractors and supersedes conflicting LCDs for the covered service.
- [NGS (Next-Generation Sequencing)](https://converus.ai/knowledge-base/glossary/#ngs): High-throughput DNA sequencing technology that can simultaneously analyze hundreds or thousands of genes in a single assay, enabling comprehensive tumor profiling for oncology treatment selection.
- [Off-Label Use](https://converus.ai/knowledge-base/glossary/#off-label): Use of an FDA-approved drug or device for an indication, patient population, dosage, or route of administration not included in the FDA-approved label.
- [Payer](https://converus.ai/knowledge-base/glossary/#payer): Any entity that reimburses healthcare providers for services, including commercial health insurers, Medicare (through CMS and MACs), Medicaid (through state agencies), and Medicare Advantage plans, each with distinct PA requirements and coverage policies.
- [PD-L1 (Programmed Death-Ligand 1)](https://converus.ai/knowledge-base/glossary/#pd-l1): A protein expressed on tumor cells and immune cells whose expression level serves as a predictive biomarker for response to checkpoint inhibitor immunotherapies, with expression thresholds defined in companion diagnostic requirements for specific indications.
- [Peer-to-Peer Review](https://converus.ai/knowledge-base/glossary/#peer-to-peer-review): A direct conversation between the ordering physician and the payer's medical director, typically requested after a medical necessity denial, that often yields the highest overturn rates of any single appeal intervention.
- [Prior Authorization](https://converus.ai/knowledge-base/glossary/#prior-authorization): A payer requirement that providers obtain advance approval before delivering a specified service, drug, or diagnostic test in order to receive reimbursement.
- [RCM (Revenue Cycle Management)](https://converus.ai/knowledge-base/glossary/#rcm): The end-to-end administrative and financial process that healthcare organizations use to track patient care episodes from registration through final payment.
- [Somatic vs. Germline Testing](https://converus.ai/knowledge-base/glossary/#somatic-germline): Somatic testing detects mutations acquired in tumor cells during a patient's lifetime; germline testing detects inherited mutations present in every cell, a distinction that determines which coverage policies, codes, and documentation requirements apply.
- [Step Therapy](https://converus.ai/knowledge-base/glossary/#step-therapy): A payer coverage requirement that a patient try one or more lower-cost or preferred treatments before the requested treatment will be authorized.
- [TMB (Tumor Mutational Burden)](https://converus.ai/knowledge-base/glossary/#tmb): A measure of the total number of mutations in a tumor's genome, used as a biomarker to identify patients who may respond to checkpoint inhibitor immunotherapy regardless of tumor type.
- [Utilization Management](https://converus.ai/knowledge-base/glossary/#utilization-management): The set of payer programs, including prior authorization, step therapy, quantity limits, and concurrent review, designed to ensure that healthcare services are clinically appropriate and cost-effective.

## Company

- [Privacy Policy](https://converus.ai/privacy.html)
- [Terms of Service](https://converus.ai/terms.html)
- [AI Usage Disclosure](https://converus.ai/ai-disclosure.html): How Converus uses AI on this website, including AI-assisted knowledge base content that is reviewed by humans before publication.