Other UF Health Locations

Confirmation of Services (COS)

COS codes and pricing can be obtained either by the study team PRIOR to an OCR submission, or alternately, by the OCR CAB team AFTER submission to OCR.

If study team will be obtaining the COS, study team requests using the following form and process: 

Instructions

Location of Services (one location per form)

  • Click on the “click here for location list”.
  • Click on the arrow on the right.
  • From the drop-down list, select the Shands Ancillary location where the services will be administered.

Study Short Name (nickname)

  • In the free-text field, enter the study short name (nickname) that will be used by the investigator and study coordinators when they reference the study. This short name will be used as an identifier for this study on all forms and will be used as the searchable “study name” when the study is in Epic ( limited to 20 characters).

Study Long Title

  • In the free-text field, enter the study title (limited to 256 characters). Note: This should match the study title as it will be submitted to your IRB and as it will be indicated on the OCR Study Registration & Initiation Checklist.

Principal Investigator

  • In the free-text field, enter the full name of the Principal Investigator. Note: This should be the same as the Principal Investigator as it will be submitted to your IRB and as it will be indicated on the OCR Study Registration & Initiation Checklist.

Other Study Investigators/Providers

  • In the free-text field enter the name of any other investigators or physicians that may be providing services for this study.

Study Contact Person Submitting Form

  • In the free-text field, enter the name and contact information for the study team member who is submitting this COS form.

Box for Shands Technical Codes and List Pricing

  • This box can either be filled out by the study team OR Shands ancillary technical COS contact.
  • Enter the name and date information pertaining to the request for confirmation of Shands technical CPT and EAP codes and Shands technical list prices.

Box for Shands Financial Planning & Analysis Technical Research Pricing

  • This box can either be filled out by the study team OR Shands Financial Planning and Analysis (FP&A).
  • Enter the name and dates information pertaining to the request for confirmation of Shands technical research prices.

Box for UFHP Professional Codes and Pricing

  • This box can either be filled out by the study team OR UFHP professional COS contact.
  • Enter the name and date information pertaining to your request for confirmation of UFHP professional CPT codes and professional list and research prices.

Special Considerations Box

  • Mark any of the special considerations boxes that apply to this study:
    • Amendment to COS pricing issued prior to 09/27/10
    • Federally Funded Study
    • Pediatric patients
    • Adult patients
    • Inpatient
    • Outpatient

Reminder

  • For budgetary purposes on multi-year studies, plan for a 5% price increase each year. Research rates are estimates. Actual charges will be the rate current on day of service.

Service Name

  • Enter the name for the service you need confirmed and priced.
  • Note: If you are not sure of the service name, you will want to contact the Shands Ancillary and get help to determine the correct service required by the study protocol. See COS Contacts (gatorlink login required).
  • This may involve emailing part of the protocol to the Service Provider so they can help make a determination of the service needed for the study.
  • The Shands Ancillary can also help you to determine if the service generates a professional fee, a technical fee, or both.
  • If more rows are required, please add more rows via Word 2010 menu Review > Restrict Editing > “Stop Protection” button > copy more rows (do not add data yet), then >”Yes, Start Enforcing” > “OK” (no password) > add row data

Anticipated Number of Participants

  • Enter the number of anticipated participants that will receive this service while enrolled in the study.

Number of Times per Participant

  • Enter the number of times this service will be provided to each participant while enrolled in the study.

CPT Code

  • Enter the CPT code for the service you need confirmed and priced.
  • Note: If you are not sure of the CPT code, you will want to contact the Service Provider and get help to determine the correct service required by the study protocol. See COS Contacts (gatorlink login required).
  • This may involve emailing part of the protocol to the Service Provider so they can help make a determination of the service needed for the study.

EAP Code

  • If you know the current EAP code for this the service, please enter. If you are not sure, leave this blank until it has been confirmed by the Shands technical COS contact.
  • If the service generates a professional fee through UF Health Physicians (UFHP), your UFHP liaison will fill in the professional list price and research estimate for the service.

Technical List Price

  • If the service generates a technical fee billed through Shands Financial Services (PFS), the Shands ancillary COS contact will fill in the technical list price for the service.

Technical Research Rate Estimate

  • If you need the research estimate for this technical service for budgeting purposes, after you have received the appropriate technical service list price, forward the COS to Theresa O’Connell OCONTA@shands.ufl.edu in Shands Financial Planning and Analysis. She will fill in the Technical Research Rate Estimate.

Professional List Price and Research Rate Estimate

  • If the service generates a professional fee billed through UF Health Physicians (UFHP), the UFHP COS contact will fill in the professional prices (list and research) for the service.

Comments

  • Use this field to explain any special requests or circumstances.

Questions?

  • Contact the OCR Coverage Analysis and Budget team via OCR-CAB@ahc.ufl.edu.
  • You can also contact the service location directly. For a comprehensive list of UF Health Research Service Locations and associated contacts, see COS Contacts (gatorlink login required).