Free None - Wisconsin

DEPARTMET OF HEALTH SERVICES Division of Public Health F-42026 (Rev. 12/08)

STATE OF WISCONSIN AIDS/HIV Program (608) 266-3495 Page 1 of 2

REIMBURSEMENT REQUEST WISCONSIN AIDS/HIV LABORATORY REIMBURSEMENT PROGRAM
Personally identifiable information on this form will only be used to verify that the client's HIV status has been reported to the Wisconsin AIDS/HIV Program INSTRUCTIONS: Please fill out one form per patient. The same form may be used to request reimbursement for more than one laboratory test for the same patient.

SECTION I. PATIENT INFORMATION
Last Name First Name Middle Initial Date of Birth

Patient Medical Record Number (Optional) Eligibility Verification (check relevant boxes): Patient is a Wisconsin resident Patient is currently uninsured

SECTION II. PROVIDER INFORMATION
Last Name Agency Name First Name Professional Designation (e.g. MD, DO, etc.) Telephone Number

SECTION III. LABORATORY INFORMATION
CPT Code (Check all the apply) CPT # 86359 CPT # 86360 CPT # 86361 CPT # 87534 CPT # 87535 CPT # 87536 CPT # 87537 CPT # 87538 CPT # 87539 CPT# 87900 CPT# 87901 CPT# 87903 CPT# 87904 CPT# 87999 (CPT Varies) Sample Collection a Date Amount of Reimbursement Requestedb $

Laboratory Name

CD4 Count/Percentage

Viral Load

$

Antiretroviral Resistance

$

CCR5 Co-receptor Trofile Assay HLA B5701 (Abacavir Hypersensitivity Assay)
a b

$ $

If sample collection date is not available, please use an alternative date and indicate which date was used Maximum reimbursement rate shown in the table on page 2 of this form

Note: Reimbursement processing will be delayed, or the request may be denied, if: · A fiscal agent for the submitting physician has not been identified, · The request form is incomplete, · Each of the patient eligibility criterion are not checked, or · If the patient's HIV status has not been reported to the AIDS/HIV Program.

Please make a copy of this request for your records and return the completed form in an envelope marked "CONFIDENTIAL" to: Division of Public Health Attn: Laboratory Reimbursement Program, Room 318 PO Box 2659 Madison, WI 53701-2659 Or fax to: (608) 266-1288 (confidential fax)

Laboratory tests covered by the Wisconsin AIDS/HIV Laboratory Reimbursement Program
CPT Code T Cells, total count T Cells, absolute CD4 and CD8 count, including ratio T Cells, absolute CD4 count Plasma HIV RNA : HIV-1, direct probe method Plasma HIV RNA : HIV-1, amplified probe method Plasma HIV RNA : HIV-1, quantification method Plasma HIV RNA : HIV-2, direct probe method Plasma HIV RNA : HIV-2, amplified probe method Plasma HIV RNA : HIV-2, quantification method Antiretroviral Resistance Testing: virtual phenotype method Antiretroviral Resistance Testing: genotype method Antiretroviral Resistance Testing: phenotype method, first 10 drugs Antiretroviral Resistance Testing: phenotype method, each additional 5 drugs tested CCR5 Co-receptor Trofile Assay HLA B5701/Abacavir Hypersensitivity Assay CPT= Current Procedural Terminology * Rates current as of December 3, 2008 86359 86360 86361 87534 87535 87536 87537 87538 87539 87900 87901 87903 87904 87999 83891, 83900, 83896, 83912 (Quest) Other CPT codes may be used by other labs Maximum Reimbursement Rate* $52.65 $65.58 $37.41 $27.99 $48.99 $118.89 $27.99 $48.99 $59.85 $165.54 $359.34 $682.04 $36.38 $1568.00 $59.32