NavDx Test Requisition Form for HPV+ Cancer Care

To submit the NavDx Test Requisition Form, attach a copy of the front and back of the patient's insurance card and patient face sheet. Submit via fax to 877.310.5073 or email to support@naveris.com. You may also send the physical form to Naveris, Inc., 21 Hickory Drive, Waltham, MA 02451. Ensure that all sections are filled out accurately, signed, and dated before submission. Confirm receipt with Naveris to avoid any delays in processing. My advice is to double-check all the details and attachments before submitting to ensure a smooth and timely process.

Important dates for submitting the NavDx Test Requisition Form are specific to each patient's treatment plan and MRD surveillance schedule. Adhere to the specified intervals, such as every 3, 6, or 12 months, as directed by the healthcare provider. No general calendar dates apply for 2024 and 2025 – follow individualized patient schedules.

The NavDx Test Requisition Form is essential for ordering the NavDx test for HPV+ cancer care. It allows healthcare providers to formally request the test by filling out necessary patient and clinical information, ensuring accurate processing and tracking. This form is crucial for documenting medical necessity, coordinating care, and facilitating reimbursement or payment. Filling out the form requires detailed input from the healthcare provider regarding patient information, clinical background, treatment history, and billing details. The form's structure helps standardize the information needed for the test and ensures all required fields are completed. Accurate completion of the form supports effective communication between the healthcare provider, the testing laboratory, and insurance companies. The ordering physician's attestation at the end of the form certifies the accuracy and necessity of the test, streamlining the approval and processing workflow for the NavDx test in the patient's treatment journey.

• 1. Ordering Healthcare Provider: Includes the provider's name, NPI, institution/practice name, address, contact information, and reporting preferences.
• 2. Patient Information: Details about the patient such as last name, first name, middle name, date of birth, sex at birth, MRN#, address, contact information, and email.
• 3. Mobile/Offsite Phlebotomy Service: Indicates if mobile/offsite phlebotomy service is required and if a kit was provided to the patient, along with the target blood draw date.
• 4. Clinical Information: Includes diagnosis, ICD-10 code, country, date of diagnosis, pathological stage, treatment history, tumor p16 status, tumor HPV status, HPV method of detection, tumor status at time of blood draw, and treatment stage at time of blood draw.
• 5. MRD Surveillance Notification Program: Specifies the frequency of TRF submission for MRD surveillance over the next 12 months.
• 6. Billing Information: Requires details about the primary and secondary insurance providers, subscriber #, group #, policyholder name and DOB, hospital status, and billing type.
• 7. Healthcare Provider Attestation: The attestation section where the ordering physician certifies the accuracy of the information and the medical necessity of the test.
• 8. For Naveris Use Only: Internal section for Naveris to document details such as volume received, date of collection, and date/time of receipt.

Failure to submit the NavDx Test Requisition Form can result in delays or inability to process the test, impacting patient care.

• Delay in Testing: A delay in testing can affect timely diagnosis and treatment planning for the patient.
• Insurance Reimbursement: Inaccurate or incomplete submission may result in denial or delay in reimbursement from insurance providers.
• Coordination of Care: Failure to submit the form can disrupt coordinated care efforts between the healthcare provider, testing laboratory, and insurance companies.
• Medical Record Documentation: Incomplete submission may lead to gaps in documenting the medical necessity and eligibility for the test.

• 1. HPV+ Cancer Patients: Order the test when treating patients diagnosed with HPV+ cancer for ongoing management and monitoring.
• 2. Post-Treatment Monitoring: Use the form to requisition the test for monitoring patients post-treatment to detect any recurrence.
• 3. Clinical Trials: Fill out the form for patients participating in clinical trials requiring the NavDx test.
• 4. Insurance Claims: Submit the form as part of insurance claims for test reimbursement.
• 5. Standardized Care Protocols: Use the form as part of standardized care protocols for HPV+ cancer care within medical institutions.