Overview

Coverage & Reimbursement Made Simple

Leverage CPT codes and proven billing workflows to ensure your pharmacogenomic insights are both effective and cost-efficient.

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Overview

Precision medicine can be a game-changer for improving patient outcomes, but cost considerations often concern providers. PGxAI’s Coverage & Reimbursement framework helps hospitals, clinics, and health systems navigate the complexities of billing for pharmacogenomic (PGx) tests and consultations. From established CPT codes to payor collaborations, our platform streamlines the reimbursement process—maximizing financial sustainability while enhancing clinical care.

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Clearly mapped CPT codes for PGx testing and analysis

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Integrated billing workflows that minimize administrative burden

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Success stories showcasing real-world reimbursement for PGx-based interventions

Integration

Seamless EHR Integration

PGxAI is pre-built for interoperability with leading EHR systems like Epic, Cerner, Allscripts, and more. Through our partnership with InterSystems IRIS for Health, oncology teams gain real-time PGx insights right in their workflow. No more juggling multiple portals or standalone apps—just instant, actionable data when you need it most.

Recognized CPT Codes

PGxAI aligns with standard CPT codes (e.g., 81225–81355 range), allowing your finance team to invoice payors accurately.

Clear Documentation

Our platform auto-generates detailed reports tied to specific tests and patient outcomes, simplifying the documentation required for claims.

Billing Workflow Integration

PGxAI can interface with practice management and billing systems, reducing manual entry and minimizing errors.

Payor Collaborations

We actively engage with private insurers and Medicare/Medicaid programs to validate coverage strategies, easing the reimbursement path for our clients.

Case Study

Lakeview Medical Center

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Challenge

High denial rates for PGx tests, leading to patient dissatisfaction and lost revenue.

Solution

Implemented PGxAI’s billing workflow and utilized CPT codes recommended by our reimbursement specialists.

Results

85% approval rate on submitted claims within six months, substantially increasing revenue and patient satisfaction.

Benefits

Serving every stakeholder in healthcare

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Reduced Financial Risk

Proper coding and documented clinical utility lower claim denials, reducing the financial burden on your organization.

Better Patient Access

When PGx tests are reimbursed, more patients can benefit from personalized treatment options, improving overall care quality.

Streamlined Administrative Processes

Automated claim generation and integrated billing reduce time-consuming manual tasks, freeing staff to focus on patient care.

Increased Revenue Potential

As PGx testing gains widespread acceptance, providers who adopt these approaches early may see enhanced revenue streams from new or expanded services.

Payor Collaborations

Serving every stakeholder in healthcare

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Private Insurers

Ongoing dialogues with major payors help to establish consistent coverage policies.

Public Programs

Our team monitors Medicare and Medicaid guidelines for new CPT codes, ensuring compliance and maximizing reimbursement opportunities.

Value-Based Care Alignment

Documented reductions in adverse drug events can translate into savings for payors and providers alike, reinforcing the value of PGx testing.

Whats next

Ready to Shape the Future of Precision Medicine?

Empower your practice with a comprehensive PGx reimbursement strategy that aligns clinical excellence with financial sustainability.

Contact Our Reimbursement Team

Get personalized guidance on payor strategies and claim submissions.

Request a Demo

See how PGxAI integrates billing workflows and CPT code mapping.

Learn More About PGxAI

Explore how our platform enhances precision medicine from test ordering to final reimbursement.