New Reference Laboratory (Send Out Test) Request Submission Portal

Selection of Reference Laboratories

Reference laboratories are chosen based upon quality of performance. Specimens must be referred only to a CLIA-certified laboratory or a laboratory meeting equivalent requirements as determined by Center for Medicare and Medicaid Services (CMS). Therefore, all requests for and approval of reference laboratories are required by the CLIA Laboratory Directors of UnityPoint Health - Des Moines Clinical Laboratories and Pathology Laboratory.

The Clinical Laboratory has a process for evaluating new test requests and qualifying reference laboratories to ensure quality of patient care, as well as compliance with accreditation requirements and applicable State/Federal laws including, but not limited to, possession of CLIA certification. New test requests will also be reviewed by the Laboratory Directors and Executive Director for medical necessity, consensus among applicable ordering providers, and cost and reimbursement. The review process for a new reference laboratory (send out test) may take approximately 8-10 weeks. Avoid collecting the specimen until the request has been approved unless previously discussed with the CLIA Laboratory Director (DM-Hospitals: Dr. Larry Anderson, MD or Pathology Laboratory: Dr. Jacob Sramek, MD).

Please contact the Kim Von Ahsen, Laboratory Quality & Safety Specialist at kimberly.vonahsen@unitypoint.org if you have any questions or concerns. Thank you!

REQUESTOR INFORMATION

Date Requested * +

Requesting Individual's Name
Please enter as follows: Last Name, First Name *

Requesting Individual Email Address
*

Requesting Individual's Phone Number *

NEW REFERENCE LABORATORY AND TEST INFORMATION

Test Name
List all applicable testing that you desire to utilize this reference laboratory. *

Approved Performing Lab*

UnityPoint - Health Des Moines Laboratories' approved Referral Lab list is available here.

If the performing lab is not listed, please complete the New Performing Lab information below.

Please note that if you choose NEW PERFORMING LAB, specimens can only be sent to laboratories with a CLIA Certificate. This information can typically be found on the laboratory website or by contacting the laboratory.

New Performing Lab Name *

CLIA Number *

New Performing Lab Address

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

New Performing Lab Justification *

Please provide additional comments for justification below *

Referral Lab's Test Code *

Referral Lab Test URL (if applicable) *

CPT/PLA/MolDx Codes
It is highly recommended that new tests have an applicable Current Procedural Terminology (CPT) code, or at least a Proprietary Laboratory Analyses (PLA) code. However, PLA codes are often granted to tests early in their availability and do not guarantee that the test has clinical validity or utility, positively impacts clinical outcomes, or will be covered by payers. *

CLINICAL INFORMATION

Medical Justification *

Patient Population *

Is this test being requested to replace a current test? *

Please entre the current test/test code below *

Estimated Total Annual Test Volume *

Estimated Cost Per Test *

The Clinical Laboratory must weigh the resources required to maintain new tests with the anticipated clinical adoption and benefits to patients across the health system in an equitable and standardized manner. Does this test request have the support of the requesting physician’s clinical colleagues, department, and/or other adminatrative leadership? Please provide additional details here. The Laboratory may contact you for additional information/clarification: *

CONFLICT OF INTEREST

Please note that any potential conflicts of interest will be forwarded to the Office of Compliance and may extend the review period for this request. *

	Yes	No
Does the requesting provider and/or their family member have a financial interest in the referred lab?	Yes	No
Is the requesting provider and/or their family member receiving remuneration from the referred lab?	Yes	No
Is the requesting provider and/or their family member employed, in any capacity, paid or unpaid, by the referred lab or test manufacturer?	Yes	No
To your knowledge, does any other UPH workforce member(s), or their family member, have a financial interest in the lab being requested?	Yes	No
Did any other UPH workforce member(s) refer you to use the lab being requested?	Yes	No

Save & Return

Use an account to return to saved work.