← Return to FSHD1 and FSHD2 Billing Directives

On the FSHD1 and FSHD2 Requisition:

Select one of the following billing options:

1. Prepayment Required – Non-Iowa resident with non-Iowa Medicaid or no insurance, or

2. Prepayment Required – The referring institution completed vetting insurance coverage. Payable benefits are unavailable, and the referring institution declines financial responsibility for the charges.

FSHD1 and FSHD2 Requisitions:

• Download the FSHD1 and FSHD2 Requisition (U.S.)
• Download the FSHD1 and FSHD2 Requisition (International)

Circumstances requiring prepayment:

• Non-Iowa resident with non-Iowa Medicaid or no insurance
• The referring institution completed vetting insurance coverage. Payable benefits are unavailable, and the referring institution declines financial responsibility for the charges.
• Non-Iowa patients with Medicare when OPTION 2 is selected in Section G
• Cases originating from outside the United States
  • ​Prepayment is mandatory unless the UIDL has specifically approved client invoicing.

Prepayment Steps:

Step 1: The referring institution reviews UIDL billing policies and determines that prepayment is required.

Step 2: The referring institution completes and submits the online prepayment form on behalf of the patient prior to specimen collection by clicking the “Fill Out the Prepayment Form” button, below. The prepayment form provides the UIDL with information required to generate a statement, via email, to the entity responsible for making payment. Below is required information to complete the prepayment form:

• Contact information specific to the individual completing the form.
• Ordering provider information (including NPI, if applicable).
• Referring institution information (including name, address, phone, and email—if applicable)
• Patient information (name, date of birth, gender, and address)
• Requested testing
• Result reporting options (fax number for institutions within the US and email for institutions outside the US)
• Guarantor email address

Fill Out The Prepayment Form

Step 3: The UIDL Reference Billing team processes the request and submits a statement of charges, via email, to the guarantor.

Step 4: The guarantor makes the required prepayment (see pricing table below). To successfully complete an online prepayment there is certain required information (e.g., account number, statement number, and US dollar amount) that must be input into the payment portal. The source of this required information is the UIDL statement of charges.

Step 5: The UIDL Reference Billing team recognizes payment and communicates receipt of payment to the referring institution—the individual who completed the prepayment form—and the guarantor.

Step 6: The referring institution sends a completed test requisition along with the specimen to the UIDL.

Step 7: The UIDL performs testing and reports results.

Step 8: If prepayment exceeds actual charges, a refund will be issued back to the credit card holder. If prepayment does not account for all charges, the UIDL will issue another statement of charges to the cardholder who will be responsible for paying the residual liability.

Applicable CPT codes and client rate for the FSHD panel and individual panel components:

• 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.

• 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.