Cost: $360. Fresh/Frozen Tissue

Transcription

1 Test Pricing and CPT Codes Bartonella epcr PCR of specimen(s) followed by combined 8-day BAPGM enrichment culture and post-enrichment PCR. Positive PCR results are verified by DNA sequence identification. Test options vary by specimen type. Triple Blood Draw CPT coding: x9; 87040X3; Cost: $864 Single Blood Draw CPT coding: x3; 87040; Cost: $480 Non-blood Fluid CPT coding: x2; 87040; Cost: $360 Fresh/Frozen Tissue CPT coding: x2; 87040; Cost: $435 Bartonella Triple Blood Draw epcr + IFA Panel PCR of specimen(s) followed by combined 8-day BAPGM enrichment culture and post-enrichment PCR. Positive PCR results are verified by DNA sequence identification. Also includes testing of serum samples for IgG antibodies against both B. henselae and B. quintana. CPT coding: x9; x3; 87150; x2 Cost: $970 Bartonella IFA Serology Testing of serum samples for IgG antibodies against B. henselae or B. quintana. CPT coding: Cost: $90 for one, $160 for two PCR Tick Panel Multiple PCRs on specimen(s) for Babesia/Theileria spp., Ehrlichia spp., Anaplasma spp., and Rickettsia spp. testing. Positive PCR results are verified by DNA sequencing. Requires whole blood sample. x4 Cost: $590 Tick Panel Individual Options Babesia/Theileria spp. Ehrlichia spp. Anaplasma spp. Rickettsia spp. Form HH134; Revised Galaxy Diagnostics Inc Kit Creek Rd, Suite 130 Research Triangle Park, NC t f www galaxydx.com

2 Test Request Form (not available in NY) Physician Information Patient Information Clinic Name Last Name First Name MI Mailing Address DOB (mm/dd/yyyy) Male Female City State Zip Code Mailing Address Phone Fax City State Zip Code Phone Referring Physician Name For Payment Receipt ICD-9 Diagnostic Codes (Required for insurance claims) Test and Sample Information Sample Type Collection Date (mm-dd-yy) Sample Type Collection Date (mm-dd-yy) SID SID SID Test Menu (Select test(s) requested) Testing Panels: Bartonella epcr Triple Blood Draw + IFA IgG Serology Panel (includes B. henselae and B. quintana serology) Bartonella IFA IgG Serology Panel (includes B. henselae and B. quintana) Tick Panel PCR (includes testing for Babesia/Theileria spp., Anaplasma spp., Ehrlichia spp., and Rickettsia spp.) Individual PCR Testing Options: Bartonella epcr Triple Blood Draw Bartonella epcr Single Blood Draw Bartonella epcr Non-blood Fluid Bartonella epcr Fresh/Frozen Tissue Bartonella spp. PCR Paraffin-Embedded Tissue Bartonella spp. PCR Individual IFA Serology Testing Options: Bartonella quintana IFA IgG Serology Bartonella henselae IFA IgG Serology Babesia/Theileria spp. PCR Anaplasma spp. PCR Ehrlichia spp. PCR Rickettsia spp. PCR **Release of Sample for Research** The release of your sample(s) for research will be used by Galaxy Diagnostics and its research partners to isolate and study specific strains of Bartonella and other pathogens. Your patient data, including your name, will not be attached to this sample. I give permission to Galaxy Diagnostics Inc. and its research partners to use part of my sample for research purposes. I do NOT want Galaxy Diagnostics Inc. and its research partners to use part of my sample for research purposes. Prepayment is required on all test orders Please submit a completed Billing Information Form Form HH132; Revised Galaxy Diagnostics Inc Kit Creek Rd, Suite 130 Research Triangle Park, NC t f www galaxydx.com Office Use Only: Lab Use Only: Data Entered / / Received / / Account # Logged by Order # Invoice #

3 Billing Information Pre-payment required on all test orders Pre-Payment Information (Patient is responsible for pre-payment) Pre-payment is required on all orders. Samples will be held until payment is received. Samples are stable for up to two weeks in refrigerator after specimen collection and may expire if prepayment is delayed. Visa / Mastercard / Amex / Discover Exp / (mm/yy) CSV Billing zip code Name on card Signature Card # Todays Date / / (mm/dd/yy) Claims Filing Patient Identification Please select one of the billing options below Self- Pay (no insurance to be filed) Please choose this option if uninsured or would not like a reimbursement claim submitted on your behalf. Primary insurance Required items include: 1) Pre-payment information (complete above) 2) Front and back copies of insurance card(s) 3) Valid photo ID A reimbursement claim will be submitted to your insurance provider. Reimbursement depends on your individual insurance plan. Any reimbursement will be directly mailed to you from your insurance provider. Following reimbursement, we may contact you for a copy of your Explanation of Benefits (EOB). Medicare (primary insurance) Required items include: 1) Pre-payment information (complete above) 2) Front and back copies of insurance card(s) 3) Valid photo ID 4) Completed Advance Beneficiary Notice Form (ABN) A reimbursement claim will be submitted to Medicare on your behalf. Reimbursement depends on your Medicare plan. Any reimbursement deemed payable by Medicare will be mailed directly to the patient from Medicare. Patient Insurance Information (For private insured/ Medicare patients only) Primary Insurance Policy Provider Name Policy/ Group Number Address of Primary Insurance Company (as indicated on Insurance card) Policy Holder ID Number Policy Holder s Name Policy Holder DOB (mm/dd/yyyy) Policy Holder Address Policy Holder Daytime Telephone Number Patient s Relationship to Policy Holder Patient s Gender Self Spouse Child Other Secondary Insurance Policy Provider Name (If applicable) Male Female Secondary Policy/ Group Number Address of Secondary Insurance Company (As indicated on Insurance card) Secondary Policy Holder ID Number Secondary Policy Holder s Name Secondary Policy Holder DOB (mm/dd/yyyy) Secondary Policy Holder Address Secondary Policy Holder Daytime Telephone Number Patient s Relationship to Secondary Policy Holder Self Spouse Child Other I authorize Galaxy Diagnostics to file medical reimbursement claims on my behalf. I understand that Galaxy Diagnostics is not currently participating with private insurance providers or Medicare. Reimbursement is dependent on my insurance policy/plan. I understand that I am responsible for pre-payment prior to receiving test results or reimbursement from my insurance provider. I may be reimbursed for the testing by my insurance provider directly or indirectly through Galaxy Diagnostics. I also authorize Galaxy Diagnostics to obtain necessary medical records to file claims on my behalf. Patient Signature Date / / (mm/dd/yy) Please provide front and back copies of your insurance card(s) Form HH135; Revised Galaxy Diagnostics Inc Kit Creek Rd, Suite 130 Research Triangle Park, NC t f www galaxydx.com

4 7020 Kit Creek Rd, Suite 130 Research Triangle Park, NC Phone: / Fax A. Notifier (Referring doctor s staff): B. Patient Name: C. Identification Number (Last 4 digits of SS): Advance Beneficiary Notice of Noncoverage (ABN) NOTE: If Medicare doesn t pay for items checked or listed in the box below, you may have to pay. Medicare does not pay for everything, even some care that you or your health care provider deem medically necessary. We expect Medicare may not pay for the items listed or checked in the box below. Choose One (below) Listed or Checked Items Only: Reason Medicare May Not Pay: D. Test Options Bartonella epcr Triple Blood Draw + IFA Panel x9; x3; 87150; x2; 87153*; ($970) Bartonella epcr Triple Blood Draw x9; x3; 87150; 87153*; ($864) Bartonella epcr Single Blood Draw x3; 87040; 87510; 87153*; ($480) Bartonella epcr Non-blood Fluid x2; 87040; 87150; 87153*; ($360) Bartonella epcr Fresh/Frozen Tissue x2; 87040; 87150; 87153*; ($435) Bartonella spp. PCR Paraffin Embedded Tissue 87471; 87153*; ($260) Bartonella spp. PCR 87471; 87153*; ($220) Bartonella IFA Serology Panel (Bartonella quintana and Bartonella henselae), IgG x2; ($160) Bartonella quintana IFA Serology, IgG ; ($90) Bartonella henselae IFA Serology, IgG ; ($90) Tick Panel PCR (Anaplasma spp., Babesia/Theileria spp., Ehrlichia spp., and Rickettsia spp.) x4; 87153*; ($590) Anaplasma spp. PCR 87798; 87153*; ($220) Babesia/Theileria spp. PCR 87798; 87153*; ($220) Ehrlichia spp. PCR 87798; 87153*; ($220) Rickettsia spp. PCR 87798; 87153*; ($220) * Service is usually paid for by Medicare but may be considered not medically reasonable and necessary or because frequency limitations have been exceeded. Estimated Cost: WHAT YOU NEED TO DO NOW: Read this notice, so you can make an informed decision about your care. Ask us any questions that you may have after you finish reading. Choose an option below about whether to receive the checked items listed in the box above. Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this. G. OPTIONS: Check only one box. We cannot choose a box for you. OPTION 1. I want the laboratory test(s) listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles. OPTION 2. I want the laboratory test(s) listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed. OPTION 3. I don t want the laboratory test(s) listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay. H. Additional Information: Galaxy Diagnostics, Inc. requires pre-payment in full for all services. This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call MEDICARE ( /TTY: ). Signing below means that you have received and understand this notice. You also receive a copy. I. Signature: J. Date: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland Form CMS-R-131 (03/11) Form Approved OMB No

5 * Specimen Checklist * Please confirm the following requirements BEFORE collecting patient specimens: TEST KIT/SPECIMEN COLLECTION TUBES HAVE NOT EXPIRED Under CLIA regulatory guidelines, we cannot process specimens collected in expired tubes. Please note the only kit components which expire are the collection tubes, so if the kit expiration date has passed, you may substitute those tubes for your own collection tubes. Please contact us before specimen collection if you are unsure about which tubes to use. PATIENT NAME AND DATE OF BIRTH ARE CLEARLY LABELED ON TUBE CLIA regulations restrict us from processing samples without patient name and DOB on each specimen collection tube. TEST REQUEST FORM IS COMPLETE WITH ALL REQUIRED PHYSICIAN AND PATIENT INFORMATION PATIENT NAME AND DATE OF BIRTH ON TUBES MATCH THE TEST REQUEST FORM FOR INSURANCE REIMBURSEMENT, YOU MUST INCLUDE THE FOLLOWING: Front and back copy of patient s insurance card Copy of patient s photo ID For Medicare patients, also include completed ABN form ONLY SHIP MONDAY THURSDAY OVERNIGHT VIA FEDEX. PLEASE DO NOT SHIP ON FRIDAYS, BEFORE HOLIDAYS, OR BY USPS!

6 Shipping Instructions Specimen collection kits contain all materials required for sample collection and shipping Contents: Specimen Collection Instructions Shipping Instructions Test Request Form Billing Information Form Advanced Beneficiary Notice of Noncoverage (ABN) Form Specimen Tubes 6-bay absorbent pouches Biosafety bag Cold pack Prepaid FedEx shipping label Before you Pack the FedEx Pack: Confirm the test kit has not expired; expiration date (listed on kit box): Under CLIA regulatory guidelines, we cannot process specimens collected in expired tubes Patient NAME and DATE OF BIRTH are labeled clearly on tube(s) CLIA regulations restrict us from processing samples without patient name and DOB on each specimen collection tube Freeze cold pack Pack for Shipping 1. Ensure that all tube tops or caps are secure and labeled properly with name and DOB. Ensure labels are securely attached to each transport tube. 2. Place labeled tubes into the absorbent pouches. Ensure that the tubes are lying side-to-side. Seal tubes inside biosafety bag. 3. Add completed test forms to pocket of biosafety bag. 4. Insert biosafety bag between fold of FROZEN cold packs. Securely close the box. 5. Label box with prepaid FedEx shipping label. 6. Call for Fedex pick up. Do not use Fedex drop boxes. Before you close the FedEx Pack: Do you have all of these items enclosed? All 3 forms fully completed with all required patient, physician, and insurance information o Test Request Form o Billing Information Form o Advanced Beneficiary Notice of Noncoverage (ABN) Form (Medicare patients only) For insurance reimbursement, include: o Front and back copy of patient s insurance card(s) o Copy of patient s photo ID Patient name and DOB on tubes MATCH test request form Specimens securely sealed in properly labeled tubes Tubes in absorbent pouches and sealed in biosafety bag Specimens wrapped in FROZEN cold pack fold and sealed in box DO NOT SHIP FRIDAY OR PRIOR TO HOLIDAYS. SHIP OVERNIGHT MON-THURS. DO NOT USE FEDEX DROP BOXES OR USPS. CALL FOR PICK UP. Form HH136; Revised Galaxy Diagnostics, Inc Kit Creek Rd, Suite 130 Research Triangle Park, NC t f www galaxydx.com

7 Specimen Collection Instructions Freeze cold pack prior to blood draws Label all specimen tubes with patient name and DOB Do not ship Friday or prior to holidays Blood and Serum Tests Bartonella epcr TM Triple Blood Draw: Paired blood and serum samples collected aseptically on three days over a 5-8 day period, stored in the refrigerator, and submitted together. Kit available. ***FREEZE COLD PACK PRIOR TO FINAL BLOOD DRAW*** Triple Draw 3 x 4ml whole blood (EDTA) 3 x 4ml blood serum (SST) Bartonella epcr TM Single Blood Draw: e.g. Mon Wed Fri One blood and serum sample set is collected aseptically on one day and submitted directly. Kit available. ***FREEZE COLD PACK PRIOR TO BLOOD DRAW*** Single Draw 4ml whole blood (EDTA) 4ml blood serum (SST) Bartonella IFA IgG Serology: One serum sample is collected aseptically on one day and submitted directly. Additional serum sample not needed when ordering a Bartonella epcr Triple Draw or Single Draw test. No kit available. IFA Serology 1ml blood serum (SST) Tick Panel or Individual Pathogen Blood Draw: One blood sample collected aseptically on one day and submitted directly. Additional blood sample not needed when ordering a Bartonella epcr Triple Draw or Single Draw test. No kit available. Panel or Individual Draw 2ml whole blood (EDTA) SST collection tube (serum) After collection, gently invert the sample a minimum of 5 times. Rest 30 minutes. Spin down for minutes at 3000 RPM to allow clotting. EDTA collection tube (whole blood): Following sample collection, gently invert the sample a minimum of 8-10 times. Label tubes with patient name and DOB. Log sample details on Test Request Form. Non-blood fluids, lymph node aspirates, or fresh/frozen biopsy tissues Bartonella epcr for non-blood fluids: ml Fluid samples should be aseptically collected in a sterile tube (no additives). Fluid samples include: joint fluid, cerebrospinal fluid, pericardial effusions, etc. Kit available. Bartonella epcr for lymph node aspirates: ml Samples should be aseptically collected and placed in a sealed sterile container. Lymph node aspirates may be injected into 1ml sterile saline in red top tube (no additives). Kit available. Bartonella epcr for fresh/frozen biopsy tissue: gram Fresh/frozen biopsy tissue should be aseptically collected and placed in sterile tube (no additives) and hydrated with 1ml sterile saline. Kit available. Antibiotics should not be administered within 2 weeks prior to collection. All samples may be stored in the refrigerator for up to 2 weeks prior to shipping. Non-blood fluids or fresh/frozen biopsy tissues may also be stored in a minus 20 C freezer until shipping. Samples may be rejected on the following basis: improper labeling of name or DOB on specimen tube, improper storage temperature, gross contamination, quantity not sufficient, sample damage/leaking, hemolysis, hyperlipidity, laboratory accident, missing required information, courier delays, or shipping on weekends or holidays. Form HH133; Revised Galaxy Diagnostics, Inc Kit Creek Rd, Suite 130 Research Triangle Park, NC t f www galaxydx.com