Neuromodulation. Checklist for Letter of Medical Necessity

Transcription

1 Checklist for Letter of Medical Necessity To: Health Care Provider From: Boston Scientific Reimbursement Services Department RE: Checklist for Letter of Medical Necessity Dear Health Care Provider, Boston Scientific has recently received a request to facilitate the insurance pre-authorization submission for one of your patients who is a candidate for the Precision Plus Spinal Cord Stimulator System. Many insurance companies require a letter of medical necessity from the physician certifying the patient s need for spinal cord stimulation therapy before they will grant a prior authorization. Boston Scientific has found that it is helpful to insurers when the Letter of Medical Necessity includes the following information documenting why the procedure or recommended course of action is needed. To expedite this process, we suggest that your Letter of Medical Necessity address the following points: Diagnosis code (ICD-9 code required) Review of treatments to date and effectiveness in addressing the patient s needs History & Physical (Preference that clinical information is dictated) Pharmacological Information (Current and past medications, duration, and dosage) Relevant procedure (CPT) and supply (HCPCS) codes Address patient s psychological suitability for the recommended treatment and whether the patient has a history of drug abuse Treatment Plan (Worker s Comp payers may require this document in advance to determine the patient s prospective outcome and approximate time line for recovery) Spinal Cord Stimulator Trial Results (Including percentage of pain relief or rating on a pain scale for Permanent SCS Implantation procedures) Referencing the above items in your Letter of Medical Necessity may be useful to insurers because it succinctly summarizes the patient s history for the utilization reviewer and addresses what other treatment options have been exhausted prior to the SCS procedure. We encourage you to refer to this checklist and review the sample prior authorization letters at to further assist you in this process. Should you have any questions, please contact our Reimbursement Services Department at Our goal is to help simplify the pre-authorization process and assist your patients in receiving the best and most expeditious treatment. Sincerely, Boston Scientific Reimbursement Services Department Disclaimer: Health economic and reimbursement information provided by Boston Scientific Corporation is gathered from third-party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules and policies. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice. Boston Scientific encourages providers to submit accurate and appropriate claims for services. It is always the provider s responsibility to determine medical necessity, the proper site for delivery of any services and to submit appropriate codes, charges, and modifiers for services that are rendered. Boston Scientific recommends that you consult with your payers, reimbursement specialists and/or legal counsel regarding coding, coverage and reimbursement matters. Boston Scientific does not promote the use of its products outside their FDA-approved label Boston Scientific Corporation and its affiliates. All rights reserved.. LMN_Checklist_ 10MAR2010

2 Pre-Authorization Reference Guide Important Resources: Reimbursement Services Hours of Operation: 5:00 a.m. to 5:00 p.m., Pacific Time Reimbursement Services Toll Free Number: Reimbursement Services Toll Free Fax Number: (Pre-authorization requests must be submitted to this number) Website: Services Provided: At the request of the Health Care Professional (HCP), Boston Scientific facilitates the preparation and submission of requests for coverage determinations, prior authorization and pre-certifications including the following: Provides information on payor policies and procedures for obtaining prior authorization Provides sample letters and information on medical necessity and appeals of denied claims Provides coordination and follow up services with payers relating to the pre-authorization process Provides education on the pre-authorization process Pre-Authorization Overview: This process involves obtaining advance notification from the health plan that medical necessity and other coverage criteria have been met, as set forth by the health plan. Boston Scientific assists patients with the pre-authorization process upon receipt of the below information. (Note: all forms referenced below can be found at Reimbursement) Consent Form: Form must be completed by providers who request that Boston Scientific assist with the pre-authorization process. By signing the form, the provider gives Boston Scientific consent to facilitate the pre-authorization process on his or her behalf Provider Intake Form: Provides relevant demographic information for the physician, ambulatory surgery center (ASC), or hospital Insurance Authorization Form: Provides general patient insurance information (Note: providers may use this form or their own) Clinical Documentation: Provides the insurer with a clinical history of treatment received prior to Precision Spinal Cord Stimulator (SCS) System recommendation. Psychiatric evaluation, letter of medical necessity, and other applicable documentation may need to be included for consideration Other: Additional information may be requested based on specific payer coverage criteria. For example, workers compensation may require a claim number and date of injury, and HMO cases may require a referral by the Primary Care Physician Disclaimer: Health economic and reimbursement information provided by Boston Scientific Corporation is gathered from third-party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules and policies. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice. Boston Scientific encourages providers to submit accurate and appropriate claims for services. It is always the provider s responsibility to determine medical necessity, the proper site for delivery of any services and to submit appropriate codes, charges, and modifiers for services that are rendered. Boston Scientific recommends that you consult with your payers, reimbursement specialists and/or legal counsel regarding coding, coverage and reimbursement matters. Boston Scientific does not promote the use of its products outside their FDA-approved label. Information included herein is current as of January 14, 2010, but is subject to change without notice Boston Scientific Corporation and its affiliates. All rights reserved. Page 1 of 2 Pre-Auth_Reference Guide_10MAR2010

3 Frequently Asked Questions SCS Pre-Authorization Q. How does Pre-authorization differ from Predetermination? A. Pre-authorization of benefits is the process that allows physicians and other healthcare providers to determine if the patient is eligible for coverage for a proposed treatment or service. It is also the process of securing authorization from a payer for a specialist and/or referral for non-emergency healthcare service. Pre-authorization of benefits does not guarantee reimbursement. Predetermination of benefits is similar to pre-authorization in that it allows services and treatment to be reviewed for medical necessity. Benefit coverage is predetermined before services are rendered and any limitation under a plan can be addressed before services are rendered. A predetermination is a courtesy, where a preauthorization is a requirement under a plan. Most predetermination requests can take 30 to 45 days, and a complete history and physical should be included. Q. Which payers require a pre-authorization for SCS procedures and therapies? A. A summary of typical pre-authorization requirements for different types of payers follows: Medicare does not pre-authorize or guarantee benefits. However, the patient must meet the Medicare criteria for SCS coverage. Medicaid requires pre-authorization for SCS procedures in many states. The pre-authorization process varies from state-to-state, so check with your local Medicaid office to determine the pre-authorization process for your state. Commercial Payers typically recommend predetermination for SCS procedures. Check with each payer to verify benefits, coverage policies, plan limitations, and/or exclusions. Workers Compensation requires pre-authorization for SCS treatment plans. Managed Care Payers: 1. Health Maintenance Organizations (HMOs). HMO members often must receive their medical treatment from physicians and facilities within the HMO network. HMOs may require a referral authorization from the primary care physician to the specialist. In addition to a referral authorization, the plan may require a separate authorization for the services to be rendered. 2. Preferred provider organizations (PPOs). These plans may not have pre-approval requirements for outpatient surgery. Members may also receive treatment from physicians and facilities outside the network, but different benefits apply. The plan may allow benefits to be pre-determined prior to a procedure or service. The center should schedule surgeries to allow for appropriate approval processing times. Predeterminations can take 30 to 45 days for an outcome. Q. How long does the pre-authorization process take? A. This is dependant on the health plan and its pre-authorization requirements. Usually, the process can take anywhere from five to 30 business days depending on how timely the health plan facilitates these requests. Disclaimer: Health economic and reimbursement information provided by Boston Scientific Corporation is gathered from third-party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules and policies. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice. Boston Scientific encourages providers to submit accurate and appropriate claims for services. It is always the provider s responsibility to determine medical necessity, the proper site for delivery of any services and to submit appropriate codes, charges, and modifiers for services that are rendered. Boston Scientific recommends that you consult with your payers, reimbursement specialists and/or legal counsel regarding coding, coverage and reimbursement matters. Boston Scientific does not promote the use of its products outside their FDA-approved label. Information included herein is current as of January 14, 2010, but is subject to change without notice Boston Scientific Corporation and its affiliates. All rights reserved. Page 2 of 2 Pre-Auth_Reference Guide_10MAR2010

4 Consent to Facilitate Pre-authorization Form to Boston Scientific Reimbursement Services Department Rye Canyon Loop Valencia, CA Fax completed Form to Consent to facilitate pre-authorization for the purpose of insurance pre-authorization to be conducted by Boston Scientific for the Precision Plus Spinal Cord Stimulator System I, (printed physician s name), authorize Boston Scientific to facilitate insurance pre-authorization assistance on my behalf for the Spinal Cord Stimulation(SCS) Trial and/or Permanent procedure for my patient(s). I give Boston Scientific the authorization to act on my behalf for the purposes of obtaining, submitting, and receiving all information for my patient (s) as it relates to the benefits inquiry and the pre-authorization process for the SCS procedure. Boston Scientific assists with the pre-authorization process by relaying information provided from the healthcare provider to the patient s health plan and does not make any representation or guarantee of coding, coverage, and payment as the final coverage decision for the SCS procedure is determined by the health plan based on actual claims for services rendered and in accordance with applicable contracts. Boston Scientific handles patient information, and is permitted to use and disclose patient information, as set forth in its Business Associate Agreement sent to you. I understand that this form must be signed by me before Boston Scientific can proceed with the pre-authorization assistance for my patient (s). I also understand that this authorization will remain active, unless revoked by me. Physician s Signature / / Date Physician s NPI#: Physician s TIN#: Practice Street Address 1: Practice Street Address 2: City: State: Zip Code: FAX completed form to the Boston Scientific Reimbursement Services Department at Please retain a copy for your records. All questions regarding this form should be directed to the Boston Scientific Reimbursement Services Department at Disclaimer: Reimbursement information provided by Boston Scientific Corporation is gathered from third-party sources and is presented for illustrative purposes only. This information does not constitute reimbursement or legal advice. Boston Scientific Corporation makes no representation or warranty regarding this information or its completeness, accuracy, timeliness, or applicability with a particular patient. Boston Scientific Corporation specifically disclaims liability or responsibility for the results or consequences of any actions taken in reliance on information in this document. Laws, regulations and payer policies concerning reimbursement are complex and change frequently. Providers are responsible for making appropriate decisions relating to coding and reimbursement submissions and for submitting accurate and appropriate claims for services. Accordingly, providers should consult with payers, reimbursement specialist and/or their legal counsel regarding coding, coverage and reimbursement matters. Information included herein is current as of March 10, 2010, but is subject to change without notice Page 1 of 1 Boston Scientific Consent to facilitate pre-authorization Form

5 Provider Intake Form Complete and Fax form to or to: Physician Information Additional Facility Information (if applicable) Additional Facility Information (if applicable) Additional Facility Information Physician: (if applicable) Additional Facility Information Practice (if Name: applicable) Additional Facility Information (if applicable) Address: Additional Facility Information (if applicable) Additional Facility Information (if applicable) Additional Facility Information (if applicable) Additional Facility Information (if applicable) Additional Facility Information (if applicable) City: Additional Facility Information State: (if applicable) Zip: Additional Phone: Facility Information (if applicable) Fax: Additional Facility Information Contact(s): (if applicable) Additional Facility Information (if applicable) Additional Facility Information (if applicable) TIN: Billing NPI: Doctor NPI: BCBS: Medicaid: UPIN: ACS: Other: Trial in Office: Yes No Please Provide Facility Information Below Facility Information Trial Perm In-Patient Hospital Outpatient Hospital Ambulatory Surgical Center Facility: Address: City: State: Zip: Phone: Fax: Contact(s): TIN: Billing NPI: BCBS: Other: Additional Facility Information (if applicable) Trial Perm In-Patient Hospital Outpatient Hospital Ambulatory Surgical Center Facility: Address: City: State: Zip: Phone: Fax: Contact(s): TIN: Billing NPI: BCBS: Other: Comments For Boston Scientific Internal Use Only SCS Sales Representative Information: Name: Phone: Territory: RBM Name: Disclaimer: Boston Scientific will work to obtain authorization on behalf of the physician and the facility, upon request. The above information must be completed in its entirety to facilitate appropriate processing. Information missing from this Form may cause delays in the pre-authorization process. Boston Scientific does not guarantee authorization or payment for services. The patient or patient s guardian remains liable for payment of services or goods received except as otherwise provided by law BSC Provider Intake Form10MAR010

6 Insurance Authorization Form Complete and Fax form to or to: Confidential If Form received in error, please contact Boston Scientific at I - Implant Center Information Practice Name: Site of Service: Implant Surgeon: Contact Number: Surgery Date: II - Patient Information Patient Name: Parent Name: Address: City: State: Zip Code: Home Phone #: DOB: Sex: III - Employer Information (Required for Workers Compensation) Employer Name: Employer Address 1: Employer Address 1: Work Phone:( ) IV - Workers Compensation Insurance Company: Adjuster: Phone: Claim #: Date of Injury: V - Primary Health Plan Information (Please attach front and back copy of health insurance card) Check Health Plan Type: HMO PPO EPO POS Medicare Worker Comp. Medicaid Other Primary Health plan Name: Address: City: State: Zip: Plan Phone #: Member Name: DOB: ID#: ID#: Group Plan #: Relationship to Patient: VI - Secondary Health Plan Information (Please attach front and back copy of health insurance card) Secondary Health plan Name: Phone #: Address: City: State: Zip: Secondary Member's Name: ID #: Group #: VII - Primary Care Physician Information (Required for HMO members) Primary Care Physician Name: Phone: Address: City: State: Zip: VIII - Authorization I authorize Boston Scientific (BSC) s Reimbursement Services Department to release pertinent information about my medical condition for the purpose of securing health insurance benefits information as it relates to the insurance pre-authorization process for the Trial and/or Permanent Spinal Cord Stimulation procedure. I also authorize BSC s Reimbursement Services Department to act as my representative and on my behalf to secure all authorization necessary from my health plan regarding my spinal cord stimulator procedure. I understand that I may revoke this authorization at any time by giving my physician or BSC a statement to withhold my personal and medical information from that time forward. Patient s Name: Patient or Legal Guardian s Signature: Relationship to patient: Date: Disclaimer: Boston Scientific will endeavor to obtain authorization from your insurance company to reimburse your healthcare provider for services or items covered by an authorization. However there is no guarantee that your healthcare provider will receive authorization or payment from your insurance company. You remain liable for payment of services or items received except as otherwise provided by law BSC Insurance Authorization Form_10MAR010

7 Statement of Medical Necessity Instructional Letter Dear Valued Boston Scientific Customer, Fax completed form to We are pleased to offer you an additional tool, our Statement of Medical Necessity Form ( Form ), to assist in the preauthorization process for the Precision Plus Spinal Cord Stimulator System for your patients. The Form provides you with an easy, check box format. You may choose to use this Form in place of, or in addition to, a letter of medical necessity. It is important to note that medical necessity requirements may vary by insurance carrier. Properly completing the form does not necessarily guarantee reimbursement by the pertinent payer. Boston Scientific is making no representation or warranty regarding coverage, and although we are assisting with the prior authorization process, the ultimate responsibility for obtaining reimbursement rests with the provider or physician. Instructions for completing the Medical Necessity Form 1. Enter the patient s full name, the physician name, name of surgery site, physician state, NPI and TIN# in the corresponding sections 2. Check the applicable Site of Surgery 3. Check the applicable SCS Procedure Type 4. Check the diagnosis code, as determined by the physician 5. Under the Physician s Order Section, select the procedure (s) and enter the corresponding number of units 6. Read the Physician Certification Section. The physician must sign and date the Form 7. Fax completed form, and all other requested clinical information, to the Boston Scientific Reimbursement Services Department at Should you have any questions, please call our Reimbursement Services Department at We are available to assist you Monday through Friday from 5:00am to 5:00pm, Pacific Time. We hope that our Statement of Medical Necessity Form will be useful to you and we look forward to continuing to serve you and your patients. Sincerely, Tonya Walters Reimbursement Services Manager Boston Scientific Disclaimer: Health economic and reimbursement information provided by Boston Scientific Corporation is gathered from third-party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules and policies. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice. Boston Scientific encourages providers to submit accurate and appropriate claims for services. It is always the provider s responsibility to determine medical necessity, the proper site for delivery of any services and to submit appropriate codes, charges, and modifiers for services that are rendered. Boston Scientific recommends that you consult with your payers, reimbursement specialists and/or legal counsel regarding coding, coverage and reimbursement matters. Boston Scientific does not promote the use of its products outside their FDA-approved label Boston Scientific Corporation and its affiliates. All rights reserved.. BSC_CMN INSTRUCTIONS Version 2_24JUN2010

8 **CONFIDENTIAL** Patient's Full Name: Physician Name: Fax completed form and supporting clinical documentation to Statement of Medical Necessity Patient's DOB: Name of Surgery Site: **CONFIDENTIAL** State: NPI #: TIN #: Site of Surgery: Physician Office ASC Outpatient Hospital Inpatient Hospital SCS Procedure Type: SCS Trial SCS Permanent Implant SCS Trial & Permanent Implant Diagnosis Codes: Check the primary code that applies This form contains a list of diagnosis, CPT and ICD-9-CM, codes commonly applicable to patients for whom spinal cord stimulation is prescribed. However, it is NOT a complete list of potentially applicable codes. If another code is applicable to your patient, please check the "Other" box or complete the "Notes" section and fill in the appropriate code Reflex sympathetic dystrophy Reflex sympathetic dyst., spec Chronic pain Reflex sympath. dyst., lower limb Chronic post-thoracotomy pain Other chronic postoperative Chronic pain due to trauma Phantom limb pain (syndrome) Causalgia of upper limb Chronic pain syndrome Mononeuritis, upper limb, unspec Causalgia of lower limb Mononeuritis multiplex Postlaminectomy synd., thoracic Postlaminectomy syndrome, lumbar Mononeuritis of lower limb, unspec Spinal stenosis, lumbar region Lumbago Brachial neuritis or radiculitis NOS Thoracic, lumbosac., neur., radicu Neuralgia, neuritis, and radicu., Sciatica Dorsal nerve root injury Other-Indicate ICD-9 Code: Pain in limb Lumbar nerve root injury Reflex sympathetic dyst., unspec Reflex sympath.dyst., upper limb Physician's Order: Check box (es) for services & supplies rendered SCS Trial Procedure Codes CPT Code Description Units Implant neuroelectrodes Analyze neurostim., 1st hour Analyze neurostim., add. 30 min C1778 L8680 Lead, neurostimulator Implt. Neurostim. electr. For Inpatient Hospital Use Only CPT Code Description Units Imp/rep/spine stim lead Ins/rep 2 pul gen, rechrg Notes Section: SCS Permanent Implant Procedure Codes CPT Code Description Units Implant neuroelectrodes Implant neuroelectrodes Insrt/redo spine n generator Analyze neurostim., 1st hour Analyze neurostim, add. 30 min. C1778 Lead, neurostimulator C1787 Patient progr, neurostim. C1820 Generator neuro rechg bat sy C1883 Adapt/ext, pacing / neuro lead (Splitter) L8680 Implt neurostim electr. L8687 Implt nrostm pls gen dua rec L8699 Prosthetic implant NOS / (Splitter) PHYSICIAN CERTIFICATION SECTION: By signing below, I certify that (1) I am the physician identified in the first section of this document, (2) I have completed this document in its entirety (or reviewed it carefully after it was completed by an employee under my direction), (3) all the information provided by me or my staff, including the patient diagnosis, CPT codes selected, and medical documentation supporting SCS: a) confirms this patient's suitability for SCS based on Medicare's National Conditions of Coverage for SCS and b) is true, accurate, and complete to the best of my knowledge. Physician Signature: Clinical documentation attached (i.e., treatment history and psychological evaluation ) Date: / / Patient's insurance information attached BSC_CMN_Version JUN2010