← Return to FSHD1 and FSHD2 Billing Directives

On the FSHD1 and FSHD2 Requisition:

Select one of the following billing options:

1. Direct Bill - Insurance, or
2. Process and Hold Specimen until Referring Institution Completes Vetting Insurance Coverage – Insurance

Download the FSHD1 and FSHD2 Requisition

The UIDL will directly bill insurance only if the following requirements are met:

Medicaid

• Non Iowa Medicaid: The UIDL is unable to file Medicaid claims outside of Iowa. Prepayment is required. Please see information about making a prepayment.

• Iowa Medicaid: The UIDL will issue a statement of charges to the guarantor upon completion of testing. No prepayment is required

Medicare

Medicare will only pay for services that it determines to be “reasonable and necessary” under section 1862(a)(1) of the Medicare Law. If Medicare determines that a particular service, although it would otherwise be covered, is not “reasonable and necessary” under the Medicare standards, Medicare will deny payment for that service or test.

All Medicare cases must be accompanied by a fully executed Advanced Beneficiary Notice (ABN). This entails:

1. Completion of sections D, E, and F. A template ABN containing this information is available for use. View ABN.
2. Selection of one option in Section G.
   • Option 1: The UIDL will file a claim on the patient’s behalf and issue a statement of charges reflecting any residual patient/guarantor responsibility after the claim is fully adjudicated.
   • Option 2:  Prepayment is required for non-Iowa patients. Please see information about making a prepayment.
     • Exception: for Iowa patients, the UIDL will issue a statement of charges to the guarantor upon completion of testing.
3. Patient signature and date in Sections I and J, respectively.

If a fully executed ABN cannot be obtained, the patient selects Option 2 from Section G, or the referring institution declines financial responsibility for the charges, testing will require prepayment. Please see information about making a prepayment.

Third-Party Payer Coverage

Patients and/or referring physicians are responsible for vetting third-party payer coverage. This includes determining whether prior authorization is needed and whether the patient has out-of-network laboratory benefits which will allow payment to the UIDL.

• Prior authorization - if prior authorization is determined to be required by the referring institution it must be obtained and sent with the specimen and paperwork.
  • When placing an order for the full panel, prior authorization must be for all component CPT codes. See table below.
    • Note, when ordering individual panel components, especially optical mapping, the UIDL strongly recommends securing a prior authorization which includes all aspects of testing. Situations may arise which require additional testing, and having a prior authorization on file that includes this testing expedites result reporting and patient care.
  • If prior authorization cannot be obtained and the referring institution declines financial responsibility for the charges:
    • Patient is a non-Iowa resident: testing will require prepayment. Please see information about making a prepayment.
    • Patient is an Iowa resident: the UIDL will issue a statement of charges to the guarantor upon completion of testing.
  • If the UIDL deems the prior authorization to be inaccurate or incomplete, the specimen will be processed and held. This action will be communicated to the referring institution, and we will request clarifying information before proceeding with testing. If the responsible billing party cannot be determined, and all billing requirements have not been met after 6 months, the test order will be canceled.
• UHC prior authorization (PA) - Three separate PAs are required to vet coverage. Please see below for details.
  • One PA is required for the detection of abnormal alleles (optical mapping)—CPT 81404.
  • One PA is required for the methylation status—CPT 81479.
  • One PA is required for NGS (SMCHD1, LRIF1, and DMNT3B)—CPT 81479.
• Out-of-network lab benefits
  • If coverage does not include out-of-network lab benefits, testing will require prepayment. Please see information about making a prepayment.

While vetting third party payer coverage, the payer will require certain pieces of information which are listed below for your convenience.

UIDL TIN: 42-6004813

UIDL NPIs:

• Technical: 1811984636
• Professional: 1265433676

Applicable CPT codes and insurance rate for each FSHD panel component:

• An order for the full FSHD1 and FSHD2 panel is not required; providers must be specific on the UIDL FSHD Test Requisition whether the full panel or individual components are requested.
  • Note, there will always be one professional charge irrespective of what test is ordered.
• An order for a full panel may not require performance of all the components, and the UIDL will only bill for the work performed.
  • Please know that the amount of testing that will ultimately be performed on a specimen when an order for the full panel is requested cannot be determined prior to the start of the testing.
  • In general, the minimum amount of testing performed is optical mapping to determine allele sizes and haplotyping.

Please refer to FSHD diagnostic workflow for more detail.