Report Maintenance: Medical Necessity Waiver Form

Definitions     Column Headings    Waiver Form Labels     Button Definitions  Design Tips     Procedures

Purpose

If an ordered test fails Medical Necessity Validation (MNV) review, an Advance Beneficiary Notice (ABN) waiver form can be signed by the patient or a guardian.

Use the Medical Necessity Form screen to create the form, also known as the MNV waiver form.

Waiver Form

The large panel on the left side of the screen is the form that you are about to design. The selection list at the right contains the labels that you type in a desired position on the form to create your format.

Three ways to create the waiver format are:

• Default Form
  Select the default form and modify the design and contents to the desired format.
  
  When you open the Medical Necessity Waiver submodule for the first time, the CyberLAB system displays a message that asks if you want to load the default waiver form?
  
  Click to display the drop-down list. Click to select an option.
  
  The options are:
  
  Yes. Select the Yes option to use the default waiver form.
  
  No. Select the No option to not choose the default waiver form. The system then displays a blank screen.

• Blank Design
  Use the blank screen to create your own design or to position and enter information that is printed in desired places on the preprinted form.

• Preprinted Form
  Use a preprinted waiver form that you have customized with your logo and other facility information. Position the labels on the form design in this submodule so that the information is printed in desired places on the preprinted form.
  
  Users can add waiver data to this form.
  
  Note: ABN waiver forms are provided by the Centers for Medicare and Medicaid Services (CMS).  

ABN Waiver Forms

The Centers for Medicare and Medicaid Services (CMS) provide approved ABN (MNV) waiver forms, known as L and G. The differences are:

• ABN-L Form
  This three-column form is the laboratory format.
  
  In the first column at the left, you use multiple &TEST-D or &TEST-A entries. In the second, frequency column, use multiple &F-TST-A entries. In the third, experimental or research column, use &SI-TST-A header entries.
  
  The &F-TST-A insert tests that you have classified as Frequency/Always Fail. The &SI-TST-A insert tests that you have classified as Screening or Investigative.

Example of Columnar Format

• ABN-G Form
  If you use the ABN-L form, you do not need defined class text. That is only required with the ABN-G form that contains a Because text box. The class text defined in the MNV setup is pulled into this text box.

Example of Because Text  Box

Note: If the Because messages are longer than one line, the user must count the number of letters in each line to determine where &STD-MSG2 or another other MSG2 is placed.

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Caution:  

To leave a screen in the CyberLAB system, always click the Exit button at the upper-right corner of the screen.  

Do not use the (red or black) X button at the top-right corner of the screen. This action can affect operation of the application.

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Definitions  

Note: The graphic above is an example.

The numbers illustrated across the screen (+--1 to +--8), identify the columns from 1 to 8, which represent the width of a standard form printed on an 8 1/2 X 11 inch sheet of paper.

The grid (+--1 to +--8) does not print on the page. The cursor starts in the first left position under the first dash (-).

Enter and maintain the column headings and date that you want to appear on the form. The location of the column headings correspond to the data that displays under them.

Waiver Form Labels

Button Definitions

Cancel
Does not accept any entries or selections that you have made and returns to the previous screen.

OK

 Accepts the entries and selections that you have made and places them in the system record.

Print All Lines

Prints an exact copy of the form that you designed.

Print Using Sample

Advances to the Select Sample screen on which you enter a specific sample ID and select the designated printer. The printed waiver form is associated with a specific Sample ID and displays the data associated with that sample.

Procedures

Note to Keyboard Users:  To navigate around a screen or scroll within a selection list, use the Tab key to move down and the Tab and Shift keys to move up. Press the Enter key to select the data.

For a shortcut key, also known as a hot key, press the Alt key and the key corresponding to the letter that is underlined, for example, Alt + O for OK.

Perform these steps:

1. When the system message displays and asks if you want to use the default waiver form, click the Yes or No button.
   
   For further information, see Waiver Form above.  
   
   Note: On a blank form, find the position and type the label that you want to appear on the form and then type field parameter.  For example,   Sample:  &SAMPLE

2. Start to populate the form. See the Tips box above.

3. To print, click one of the two print buttons:
   
   Print All Lines
   Press this button to print all the data indicated by the parameters on the form. Use this button to print the current waiver design.
   
   Print Using Sample
   Press this button to advance to the Select Sample screen. On the screen, you identify the specific Sample ID and select a printer. Use this button to associate the waiver form with a specific Sample ID and data from the selected Sample ID displays.

4. To accept the entries positioned on the form but not printed yet, click the OK button.
   
   Or, click the Cancel button to NOT accept the entries on the form and return to the previous screen.