Reimbursement

Benefit Verification

• Contact payers to ensure and verify patient coverage
• Communicate to physician's office the exact, payer-specific steps for submitting a claim

Prior Authorization

• File and track prior authorizations
• Determine documentation needs for payer to render a decision
• Review medical literature to identify clinical information that will strengthen the case
• Follow until payer issues a decision and notify both patient and physician about coverage outcome

Claims Tracking

• Research and track outstanding claims that are overdue according to payer's guidelines
• Seek claims adjustments to ensure fair and adequate reimbursement levels:
  • Contact payer to secure status
  • Review any issue that affects potential claim approval
  • Secure payment date from payers

Appeals

• Research, author, and follow up on medical appeals:
  • Present evidence from peer-reviewed studies
  • Discuss patient's condition and the course of treatment
  • Include physician's rationale for the prescribed course of therapy
• Provide support for appeals through three levels:

1) Initiate appeal submission; 2) Fair Hearing; and 3) Administrative Law Judge

Alternative Funding

• Interview patient to identify potential sources of alternative funding
• Contact sources to secure a commitment to cover therapy
• Complete the necessary paperwork to release funds for patient
• Notify patient and referring physician about outcome

Patient Assistance Program (PAP)

• Distribute PAP qualifications form to physician's office
• Assess case based on program criteria and send status of eligibility letter to physician and patient
• Coordinate product delivery to physicians through distribution partner