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2003
New Regulations Index
About
The New AMS Universal Test Request
Form
Step-By-Step Instructions For Completion
Of The AMS Universal Test Request
Form
How To Properly Execute The New CMS-R131-L
ABN In Seven Easy Steps
August 26, 2003
AFFILIATED MEDICAL SERVICES LABORATORY, INC.
WICHITA, KANSAS
FOR IMMEDIATE RELEASE
ABOUT
THE NEW AMS UNIVERSAL TEST REQUEST FORM
The new
AMS Universal Test Request Form is now
being implemented to comply with very
specific instructions communicated by
the Federal Government to all healthcare
providers, especially with regard to
completion of the new Advance Beneficiary
Notice (ABN). New instructions for CMS-R-131-L-ABN,
now specify content and type size that
no longer make it feasible to combine
the test request form and ABN in a single
form and maintain a reasonable size.
AMS is now combining the Medicare/Medicaid
form and the non-Medicare form into a
new, single, test requisition that retains
the features of the two previous forms,
and is for use with any billing option,
Medicare, Medicaid, Physician (client)
bill, Private Insurance, or Patient bill.
The ABN, previously attached to the Medicare
form, will now be supplied in separate
padded three-part sets, and must accompany the
test request form to the laboratory if
required and executed. Each ABN set will
provide copies for the test requesting
entity, the Patient/Beneficiary, and
a copy for referral to the laboratory.
The add-on feature is retained on the
new Universal Form for use on Non-Medicare
patients only.
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August 26, 2003
AFFILIATED MEDICAL SERVICES LABORATORY, INC.
WICHITA, KANSAS
FOR IMMEDIATE RELEASE
STEP-BY-STEP
INSTRUCTIONS FOR COMPLETION OF THE
AMS UNIVERSAL TEST REQUEST FORM
Using
the Universal Form for Non-Medicare / Non- Medicaid Patients
and billing direct to physician account.
At top of form in Section A,
check mark billing preference.
- Account/Client
Bill
- Patient
Bill
- Medicare
- Medicaid
- Insurance
- Is
Medicare Primary Payor for This
Patient: Yes/No
Step
1
Complete minimum required information
in Section
B blue shaded boxes
1, 2, (if desired on report)
3,
(telephone optional)
4, 5, 6, 7, 8 & 9
(if test requires)
11, 12.
Step 2
Check mark
any desired panel(s)
in
Section
D.
Check mark any
add-on testing in Section
E (printed
in green) and check
mark any additional
tests from the
individual listing in Section
F, or write in
the test
name
and
test code
if test(s) are
not pre-printed
on form in the “other tests” box
at bottom of the
form.
Using the form for Medicare / Medicaid
Patients and Laboratory billing directly
to these government programs.
At top of form in Section A, check
mark that billing is direct to Medicare
or
Medicaid, and
check mark yes or no to Medicare Secondary
Payor question.
Step 1
Complete
minimum required
information in
Section
B, (same
as above).
Step 2
Move to
Section
C and
complete all
required information
in pink shaded
boxes
applicable to
the filing of
a claim to Medicare
or Medicaid,
boxes 13
through 29,
and remember
to check mark
the box
indicating that
Medicare is the
primary in Section
A.
Step 3
Check mark
any desired panel(s)
in Section
D,
and provide the
required ICD-9
code(s) in the
spaces provided
for coding
panels. Remember
that add-on tests
in green print
(Section E) can
not be ordered
on Medicare/Medicaid
patients.
Step 4
Move to
Section
F individual
tests, and Check
mark clearly
any desired tests,
and provide the
required ICD-9
code(s)
in the pink shaded
code column beside
the test requested.
Special Note:
It is always
recommended that
you include a
copy of the current
Medicare, Medicaid,
or private insurance
card to insure
billing accuracy
and reduce
calls to your
office for missing
information.
Using the Universal
Form when the
laboratory
is requested to
bill the Patient
Directly,
or Patients
Private Insurance.
Step 1
Complete
the Universal
Form same
as above examples
and provide
all required
information
in Sections
A, B and C that
is required
to properly
file a claim
with the patient’s
insurance,
or to bill
the patient
directly.
Please
include a
copy of the
current
insurance card
to insure billing
accuracy.
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August 26, 2003
AFFILIATED MEDICAL SERVICES LABORATORY, INC.
WICHITA, KANSAS
FOR IMMEDIATE RELEASE
HOW
TO PROPERLY EXECUTE THE NEW CMS-R131-L
ABN IN SEVEN EASY STEPS
The AMS
supplied ABN is provided in three part
sets. The front white copy (1) must accompany
the test request form
to the laboratory.
The second pink copy (2) should be provided
to the patient.
The physician office or entity presenting
the ABN to the patient should retain
the third (3) yellow copy. Each copy
is identified for distribution.
Step 1
Peel off one specimen ID label from
the AMS Universal Test Request Form containing
your account number and the order number
and place it in the box located at the
upper left corner of the ABN. This is a
critical step as it ties the ABN to the
specific requisition, your account, and
the order number.
Step 2
Write patient's name and Medicare
# at the top of the form in the space provided.
Step 3
AMS has pre-printed the tests subject
to the ABN in three columns that identify
the reason for possible denial of payment.
Check mark the appropriate test(s) in the
appropriate column(s).
Step 4
In the space provided, write the
estimated cost to the patient if Medicare
denies payment to the laboratory. See the
AMS supplied test cost sheet for accurate
patient costs.
Step 5
Have patient read, and review with
them the options # 1 and # 2 about receiving
or not receiving the services requested
by the physician. Patient should check
mark the appropriate box.
Step 6
Patient should sign and date the
ABN.
Step 7
Present patient a copy of the signed
ABN for their records. Retain Client copy
for office records, and send Lab copy with
specimen and test request form. Please
staple or clip to the patient test requisition.
A final note: CMS considers
the test requisition provided by the laboratory
and the CMS supplied ABN as legal documents
to be used appropriately. These forms
are subject to on-demand review by any Federal oversight agency when investigating
any consumer/patient complaint concerning services provided. Failure to accurately
use these forms and adhere to all elements of compliance may place both the laboratory
and physician at risk of violating federal regulations pertaining to utilization
of laboratory testing. Always execute these forms with the thought that federal
authorities might review them. Failure to obtain the ABN before the service is
provided will leave the laboratory no choice except to bill the physician/client
directly for the services provided.
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