Pathology & Laboratory MedicineNew Send Out (Reference Lab) Test Request Submission Portal

Pathology & Laboratory Medicine

New Send Out (Reference Lab) Test Request Submission Portal

In accordance with HS 1309, please complete the survey below to request approval for a new test that is not orderable in CareConnect.

The Department of Pathology and Laboratory Medicine 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 and a California State Laboratory license. New test requests will also be reviewed by the Laboratory Stewardship Task Force for medical necessity, consensus among applicable ordering providers, and cost and reimbursement. The review process for a new laboratory test may take approximately 8-10 weeks. Avoid collecting the specimen until the request has been approved.

Please contact the Laboratory at LabSupportMngmntGrp@mednet.ucla.edu if you have any questions or concerns. Thank you!

NOTICE: CALIFORNIA LICENSE REQUIREMENTS

Please note that if the new performing laboratory does not have both a CLIA Certificate AND a State of California Clinical Laboratory License, they cannot be used in accordance with HS 1309 and state and federal regulations. Thus, please do not submit this form, as we cannot send any specimens to the NEW PERFORMING LAB. However, if you are interested in utilizing the NEW PERFORMING LAB or need assistance determining licensure status, please contact the Laboratory at LabSupportMngmntGrp@mednet.ucla.edu.

REQUESTOR INFORMATION

Requesting Provider Name*

Please enter as follows: Last Name, First Name

Requesting Provider Email Address*

Requesting Provider Phone Number*

Please enter as follows: 1234567890

Requesting Provider Pager Number*

Please enter as follows: 1234

Requesting Provider Entity*

If you are unsure what entity you are a part of, please refer to this diagram.

Select

UCLA Health System Unit*

Select

DGSOM Unit*

If your DGSOM unit is not listed below, please select "Other."

Select

Lab Section*

Select

Medicine Section*

Select

Pediatrics Section*

Select

Psychiatry Section*

Select

Surgery Section*

Select

Please enter your DGSOM unit below.*

Please enter your UCLA Health System unit below.*

ALTERNATE CONTACT

Please check the box below if there is an alternate contact other than the requesting provider above

Name of contact person (if other than the requesting physician)*

Last Name, First Name

Alternate Contact Title*

Alternate Contact Phone*

Alternate Contact Pager*

NEW PERFORMING LAB AND TEST INFORMATION

Test Name*

Approved Performing Lab*

UCLA Health's approved Referral Lab list is available here.

If the performing lab is not listed below, please select NEW PERFORMING LAB.

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

If the laboratory does not have both a CLIA Certificate AND a State of California Clinical Laboratory License, they cannot be used in accordance with HS 1309 and state and federal regulations. Thus, please do not submit this form, as we cannot send any specimens to the NEW PERFORMING LAB. However, if you are interested in utilizing the NEW PERFORMING LAB or need assistance determining licensure status, please contact the Laboratory at LabSupportMngmntGrp@mednet.ucla.edu.

Please note that UCLA Health's primary reference laboratory contract is with ARUP Laboratories. If the test is performed at ARUP, ARUP should be the performing lab unless a strong justification can be provided for the new performing lab. You can search ARUP's test menu here.

Select

New Performing Lab Name*

New Performing Lab Address*

Street Address, City, State, Zip Code

New Performing Lab Justification*

Select

Please provide additional comments for your 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, in order to be added to the UCLA Health CareConnect test formulary. 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?*

Select

Please enter the current test/test code below*

Estimated Number of Patients Tested Annually*

Estimated Total Annual Number of Test Orders*

Please note that this number will differ from the estimated number of patients tested annually if more than one test is ordered per patient.

Estimated Cost Per Test*

The Laboratory must weigh the resources required to build and 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 division chair? 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.

Does the requesting provider and/or their family member have a financial interest in the referred lab?*

Select

Is the requesting provider and/or their family member receiving remuneration from the referred lab?*

Select

Is the requesting provider and/or their family member employed, in any capacity, paid or unpaid, by the referred lab or test manufacturer?*

Select

To your knowledge, does any other UCLA workforce member(s), or their family member, have a financial interest in the lab being requested?*

Select

If there is a financial interest, please list the workforce member(s) name below*

If there is a financial interest, please list the workforce member(s) affiliation below*

Did any other UCLA workforce member(s) refer you to use the lab being requested?*

Select

If another workforce member(s) referred you, please list their name below*

If another workforce member(s) referred you, please list their affiliation below*

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