Information Kit

Easy Access to Reimbursement
Information and Support
Information Kit
This kit offers helpful information for successfully using PROCRITline®, a service that takes the guesswork out
of the PROCRIT® (epoetin alfa) reimbursement process for physicians and billing professionals.
The information in this kit, along with the links below to the Business Associate Contract and Benefit Investigation
Form, provides the basic support needed to initiate services through PROCRITline®.
And, if you have any questions, your personal PROCRITline® Site Coordinator is ready with answers via phone,
fax, or e-mail through PROCRITline® Provider eSupport. The PROCRITline® team looks forward to working
with you!
Additional Information and Forms
PROCRITline® Business Associate
Contract (BAC)
PROCRITline® Benefit Investigation
Form (BIF)
The BAC is an agreement between your office
and LASH Group, Inc., the administrator of
PROCRITline®. Read ahead to learn more about
the BAC.
The BIF requests patient information that allows
PROCRITline® to research and verify patients’ eligibility
for PROCRIT® treatment. PROCRITline® will then issue
a Summary of Benefits to the office within 48 hours,
saving time in the insurance reimbursement process.
Read ahead to learn more about the BIF.
Please click here to read the Prescribing Information, including Boxed Warnings and
MEDICATION GUIDE, for PROCRIT® (epoetin alfa).
Business Associate Contract (BAC)
Understanding the BAC
A BAC is an agreement between your office,
Janssen Products LP, and LASH Group, Inc., the
administrator of PROCRITline®.
With an executed BAC on file, PROCRITline®
can complete a benefit investigation
without requiring individual patient
authorization.
Additionally, with a BAC, your office will
be able to sign up on PROCRITline®
Provider eSupport—a fast, online, easy
way to verify insurance benefits for your
patients who use PROCRIT® (epoetin alfa).
Read ahead to learn more about
PROCRITline® Provider eSupport.
Getting started is easy
our office can call PROCRITline® to
Y
request a BAC or download one
from PROCRITline.com.
The executed BAC will need to
be faxed to 1-800-987-5572.
Once you’ve returned the BAC,
you’re ready to take advantage
of the support services of
PROCRITline® without requiring
patient signature on the BIF.
Benefit Investigation
Benefit
investigation made easy
Understanding the insurance reimbursement process can be difficult, which is why
PROCRITline is here to help you understand when you have questions.
®
etting answers to your reimbursement questions starts with calling PROCRITline
G
and completing a BIF, which initiates the research and identification of a patient’s
specific health insurance policy and specific product or treatment coverage.
®
etermining your health insurance
D
coverage for PROCRIT ® (epoetin alfa)
F
ill out a BIF with your patient, have him/her sign
the patient authorization, and fax the form to
PROCRITline at 1-800-987-5572. You may also
call PROCRITline at 1-800-553-3851 to fill out
a BIF over the phone with a PROCRITline
site coordinator. If registered on
PROCRITline Provider eSupport
(www.PROCRITlineProviderESupport.com),
you may log in and complete a BIF online.
®
®
®
®
PROCRITline will fax back to you a Summary
of Benefits within 48 hours outlining the
details of your patient’s health insurance
coverage for PROCRIT .
®
®
Benefi t Investi gation
Form for PROCR IT ®
(epoet in alfa)
Please complete and fax
this form to 1-800-987-5572
or mail to PROCRITLine®
Is this patient on dialysis?
, PO Box 220247, Charlotte,
NC 28222-0247.
If yes, do not complet
e this form. Call PROCRIT
Patient Informat ion
Line ® at 1-800-5 53-3851
.
PATIENT NAME
NAME OF GUARDIAN (IF
PATIENT ADDRESS
PRIMARY PHONE
CITY
Insuranc e Informat
ion
SECONDARY PHONE
[ ] MALE [ ] FEMALE
STATE
PRIMARY INSURANCE PHONE
SECONDARY INSURANC
CARDHOLDER
SECONDARY INSURANC
E PHONE
CARDHOLDER
CARDHOLDER DOB (MM/DD/
YYYY)
RELATIONSHIP TO CARDHOL
DER
POLICY #
E
CARDHOLDER DOB (MM/DD/
YYYY)
RELATIONSHIP TO CARDHOL
DER
POLICY #
GROUP #
PROVIDER ID # FOR INSURANC
E
GROUP #
PROVIDER ID # FOR INSURANC
Patient Authoriz ation
E
for PROCRIT Line ® Services
My signature below certifies
that I have read, understan
Janssen Products, LP,
d, and agree to the patient
and companies working
authorization to release
on their behalf, including
PROCRITLine® as defined
my protected health informatio
vendors, other affiliates,
on the patient copy (collective
n to
specialty pharmacies, and
ly, “Janssen”).
other service providers
PATIENT SIGNATURE
supporting
If patient cannot sign, patient’s
DATE
legally authorized representa
PATIENT NAME
tive must sign below.
PATIENT NAME
BY
Signature of person
legally authoriz
ed to sign for patient
NAME OF PERSON LEGALLY
AUTHORIZED TO SIGN
Physicia n Informat ion
NAME OF FACILITY
RELATIONSHIP
MEDICARE PROVIDER ID
NAME OF PHYSICIAN
ADDRESS
#
SPECIALTY
PHONE
CITY
OFFICE CONTACT
FAX
TAX ID #
PREFERRED SITE OF SERVICE
PHONE
MEDICAID PROVIDER ID
STATE
#
ZIP CODE
OFFICE CONTACT PHONE
(CHECK ONE):
[ ] PRESCRIBING MD’S
OFFICE
[ ] HOME INFUSION/INFUSIO
Drug Therapy
NPI #
[ ] NONPRESCRIBING
MD’S OFFICE [ ] HOSPITAL
OUTPATIENT
N PROVIDER COMPANY
[ ] OTHER
PATIENT DIAGNOSIS
PROCRIT ® ONLY: HAS
PATIENT STARTED
ICD-9 CODES
PROCRIT® THERAPY?
[ ] YES [ ] NO - IF YES,
START DATE
FOR CANCER PATIENTS
, IS THE PATIENT ON CHEMOTH
INITIAL HCT
INITIAL HB
ERAPY? [ ] YES [
FOR NEPHROLOGY PATIENTS
] NO
, WHAT IS THE PATIENT’S
: SERUM CREATININE
IS THE PATIENT TAKING
CREATININE CLEARANCE
PROCRIT® PRE-OPERATIVELY?
[ ] YES [ ] NO - IF
Prior Authoriz ation:
YES, SURGERY TYPE
If you would like PROCRIT
appropri ate box(es).
Line ® to provide support
for the prior authoriz
ation process, please
check the
[ ] PRIOR AUTHOR IZATION
FORM PREPAR ATION
By checking this box, I
[ ] PRIOR AUTHOR IZATION
request
STATUS MONITO RING
requirements of this patient’s that PROCRITline® assist my office in providing
the
health plan related to prior
By checking this box, I
PROCRIT®. I understan
authorization for treatment
request
d that assistance includes
with
the status of the prior authorizathat PROCRITline® actively monitor
obtaining the health plan-spec
authorization form, and
tion submission. I request
providing it based upon
PROCRITline® provide status
the patient-specific informatio ific prior
that
this form. I understand
updates to my office with
that the
n provided on patient’s
respect to this
to my office by PROCRITl ® partially complete prior authorization form
prior authorization for treatment
will be provided
ine for possible completio
with PROCRIT®.
n and submission to the
health plan.
NG INFORMATION, INCLUDING
BOXED WARNINGS, AND
MEDICATION GUIDE, FOR
PROCRIT® (EPOETIN ALFA)
AVAILABLE AT WWW.PRO
Patient co-payment requirements (such as co-payments, deductibles,
and out-of-pocket maximums)
Coverage restrictions
Benefit restrictions
ZIP CODE
PRIMARY INSURANCE
PLEASE SEE FULL PRESCRIBI
Summary of Benefits includes:
1-800-5 53-3851 DOB (MM/DD/YYYY)
APPLICABLE)
Other insurance requirements specific to a patient’s health insurance policy
CRIT.COM.
Prior Authorization Assistance
Benefit Investigation Form for PROCRIT ® (epoetin alfa)
1-800-553-3851 Please complete and fax this form to 1-800-987-5572 or mail to PROCRITLine®, PO Box 220247, Charlotte, NC 28222-0247.
Is this patient on dialysis? If yes, do not complete this form. Call PROCRITLine ® at 1-800-553-3851.
Patient Information
PATIENT NAME
Understanding prior authorization
DOB (MM/DD/YYYY)
[ ] MALE [ ] FEMALE
NAME OF GUARDIAN (IF APPLICABLE)
PATIENT ADDRESS
CITY
STATE
PRIMARY PHONE
SECONDARY PHONE
ZIP CODE
Insurance Information
Prior authorization is the process by which an insurance plan determines whether
a product or service is medically necessary for a particular patient, and whether the plan
is likely to pay for the product or service provided.
Prior authorization by an insurance company is not a guarantee of payment for a product
or service but is one requirement for payment if a product or service provided actually
satisfies the plan’s requirements.
PRIMARY INSURANCE
SECONDARY INSURANCE
PRIMARY INSURANCE PHONE
SECONDARY INSURANCE PHONE
CARDHOLDER
CARDHOLDER
CARDHOLDER DOB (MM/DD/YYYY)
CARDHOLDER DOB (MM/DD/YYYY)
RELATIONSHIP TO CARDHOLDER
RELATIONSHIP TO CARDHOLDER
POLICY #
GROUP #
POLICY #
PROVIDER ID # FOR INSURANCE
GROUP #
PROVIDER ID # FOR INSURANCE
Patient Authorization for PROCRITLine ® Services
My signature below certifies that I have read, understand, and agree to the patient authorization to release my protected health information to
Janssen Products, LP, and companies working on their behalf, including vendors, other affiliates, specialty pharmacies, and other service providers supporting
PROCRITLine® as defined on the patient copy (collectively, “Janssen”).
PATIENT SIGNATURE
DATE
PATIENT NAME
If patient cannot sign, patient’s legally authorized representative must sign below.
PATIENT NAME
BY
Signature of person legally authorized to sign for patient
NAME OF PERSON LEGALLY AUTHORIZED TO SIGN
RELATIONSHIP
PHONE
Physician Information
NAME OF FACILITY
MEDICARE PROVIDER ID #
NAME OF PHYSICIAN
ADDRESS
Request prior authorization support
Check the appropriate box(es) on the
PROCRITline® BIF to take advantage of
prior authorization support services.
Prior Authorization Form Preparation
Prior Authorization Status Monitoring
MEDICAID PROVIDER ID #
SPECIALTY
Benef it Invest igatio
n Form for PROCR IT ®
(epoe tin alfa) CITY
Please complete and fax
this form to 1-800-987-5572
or mail to PROCRITLine® FAX
Is this patient on dialysis
, PO Box 220247, Charlotte
, NC
? If yes, do not comple
te this form. Call PROCRI
OFFICE CONTACT
OFFICE CONTACT
PHONE 28222-0247.
Patient Informa tion
TLine ® at 1-800-5 53-385
1.
TAX ID #
NPI #
PATIENT NAME
PHONE
PREFERREDNAME
SITE OF
OF SERVICE (CHECK ONE):
GUARDIAN (IF APPLICA
PATIENT ADDRESS
BLE)
STATE
ZIP CODE
1-800-5 53-385 1 [ ] PRESCRIBING MD’S OFFICE [ ]DOB
NONPRESCRIBING MD’S OFFICE [ ] HOSPITAL OUTPATIENT
(MM/DD/YYYY)
[ ] MALE [ ] FEMALE
[ ] HOME INFUSION/INFUSION PROVIDER COMPANY [ ] OTHER
PRIMARY PHONE
Drug Therapy
CITY
STATE
SECONDARY
Insuran ce
PATIENT DIAGNOSIS Informa tion
ICD-9 CODESPHONE
PRIMARY
CE
PROCRIT ® ONLY: INSURAN
HAS PATIENT
STARTED PROCRIT® THERAPY? [ ] YES [ ] NO - IF YES, START DATE
PRIMARY INSURANCE PHONE
FOR CANCER PATIENTS, IS THE PATIENT ON CHEMOTHERAPY? [ ] YES
CARDHOLDER
FOR NEPHROLOGY PATIENTS, WHAT IS THE PATIENT’S:
CARDHOLDER DOB (MM/DD
ZIP CODE
INITIAL HCT
SECONDARY INSURANCE
INITIAL HB
[ ] NO
SECONDARY INSURANCE
PHONE
CARDHOLDER
SERUM CREATININE
CREATININE CLEARANCE
/YYYY)
IS THETOPATIENT TAKING PROCRIT® PRE-OPERATIVELY? [ ] YES CARDHO
[ ] NO
- IF YES, SURGERY TYPE
RELATIONSHIP
LDER DOB (MM/DD/YYYY)
CARDHOLDER
POLICY #
RELATIO
NSHIP
Prior Authorization:
If you would likeGROUP
PROCRITLine ® to provide support
for the
prior
authorization
process, please check the
TO CARDHO
LDER
#
appropriate
box(es).
PROVIDE
POLICY #
R ID # FOR INSURAN
CE
GROUP #
PROVIDER ID # FOR
[ ] INSURAN
PRIOR CE
AUTHORIZATION STATUS MONITORING
Authori zation FORM
[ ] PRIORPatient
AUTHORIZATION
PREPARATION
for PROCRI
®
TLine Service s
My this
signatur
By checking
box,e below
I request
thatthat
PROCRITline® assist my office in providing the
By checking this box, I request that PROCRITline® actively monitor
certifies
I have read, understand,
Janssen
and agree to for
Products
requirements
of this
patient’s
health
planesrelated
to prior authorization
with
the status of the prior authorization submission. I request that
, LP, and
the treatment
patient authoriza
compani
working on their behalf,
tion to release my protecte
Line® as that
including
d health
defined
. I understand
assistance
includes
obtaining the health
plan-specific
prior
status
updates
PROCRIT®PROCRIT
PROCRITline® provide
vendors, other
informat
on the patient
ion toto my office with respect to this
affiliates, specialty
copy (collectiv
ely, “Janssen”).
pharmacies, and other
®.
authorization
form,
and providing
it based upon the patient-specific
information provided on patient’s
prior authorizationservice
for treatment
PROCRIT
PATIENT
providers with
SIGNATU
supporti
RE
ng
this form.If Ipatient
understand that the partially complete prior authorization form will be provided
cannot sign, patient’s legally
DATE
® for possible
PATIENT NAME
authorize
to my office by PROCRITline
completion
and
submission
to
the
health
plan.
d represent
ative must sign below.
PATIENT NAME
BY
Sign the form and fax to 1-800-987-5572
Signature of person
legally authori
NAME OF PERSON LEGALLY
zed to sign for
AUTHORIZED TO SIGN
patient
Physici an Informa tion
RELATIONSHIP
PHONE
PLEASE SEE
FULL
INFORMATION, INCLUDING BOXED WARNINGS, AND MEDICATION GUIDE, FOR PROCRIT® (EPOETIN ALFA) AVAILABLE AT WWW.PROCRIT.COM.
NAME
OF PRESCRIBING
FACILITY
MEDICARE PROVIDER ID
NAME OF PHYSICIAN
ADDRESS
CITY
OFFICE CONTACT
FAX
TAX ID #
PREFERRED SITE OF SERVICE
Research of the patient’s health plan for prior authorization requirements
and forms
Prepopulation of the Prior Authorization
Form with patient-specific information
provided on the BIF for review and
possible submission to the health plan
Active monitoring of the status of the
prior authorization submission
MEDICAID PROVIDER ID
STATE
#
ZIP CODE
OFFICE CONTACT PHONE
(CHECK ONE):
[ ] PRESCRIBING MD’S
OFFICE
[ ] HOME INFUSION/INFUS
Drug Therap y
Prior authorization support includes:
#
SPECIALTY
PHONE
NPI #
[ ] NONPRESCRIBING
MD’S OFFICE [ ] HOSPITA
L OUTPATIENT
ION PROVIDER COMPAN
Y [ ] OTHER
PATIENT DIAGNOSIS
PROCRI T ® ONLY: HAS
PATIENT STARTED
ICD-9 CODES
PROCRIT® THERAPY?
[ ] YES [ ] NO - IF YES,
START DATE
FOR CANCER PATIENTS,
IS THE PATIENT ON CHEMOT
INITIAL HCT
INITIAL HB
HERAPY? [ ] YES [
FOR NEPHROLOGY PATIENT
] NO
S, WHAT IS THE PATIENT
’S: SERUM CREATININE
IS THE PATIENT TAKING
CREATININE CLEARANCE
PROCRIT® PRE-OPERATIVEL
Y? [ ] YES [ ] NO
Prior Authori zation:
IF YES, SURGERY TYPE
If you would like PROCRI
® to
approp riate box(es)
TLine
provide
support for the prior
.
authori zation process
, please check the
[ ] PRIOR AUTHOR IZATION
FORM PREPAR ATION
By checking this box, I
[ ] PRIOR AUTHOR IZATION
request
STATUS MONITO RING
requirements of this patient’s that PROCRITline® assist my office in providing
the
health plan related to prior
By
checking
PROCRIT®. I understand
this
authoriza
box,
I request
tion for treatment with
that assistance includes
the status of the prior authorizathat PROCRITline® actively monitor
obtaining the health plan-spe
authorization form, and
tion submission. I request
providing it based upon
PROCRITline® provide status
the patient-specific informat cific prior
that
this form. I understand
updates to
that the partially complete
ion provided on patient’s
prior authorization form
to my office by PROCRIT
prior authorization for treatmenmy office with respect to this
will be provided
line® for possible completi
t with PROCRIT®.
on and submission to the
health plan.
PLEASE SEE FULL PRESCRIB
ING INFORMATION, INCLUDIN
G BOXED WARNINGS, AND
MEDICATION GUIDE, FOR
PROCRIT® (EPOETIN ALFA)
AVAILABLE AT WWW.PR
OCRIT.COM.
Additional Services for You and Your Patients
Appeal process and procedure research
In some cases, the insurance provider may deny insured patients coverage for a
specific drug treatment. If a patient chooses to appeal the denial, PROCRITline® may be
able to help identify the procedures and processes necessary for filing an appeals claim
with the insurance company.
Alternative sources of payment
If you have a patient who cannot afford the out-of-pocket costs of treatment, PROCRITline®
may be able to help. PROCRITline® can identify alternate sources of funding, such as a patient
assistance program. A comprehensive list of programs is also available at
http://www.janssenprescriptionassistance.com/PROCRIT-cost-assistance.
General billing and coding questions
Answers to general billing and coding questions are available by calling
PROCRITline®, and online at PROCRITline.com.
Single point of contact
Because ease of use and positive relationships are important to us, PROCRITline®
offers the convenience of a single point of contact for you related to access and
reimbursement. Providers will be assigned a Site Coordinator and can speak with
the same representative each t ime they call PROCRITline®.
Online Tools
Provider eSupport
www.PROCRITlineProviderESupport.com
PROCRITline® Provider eSupport is an
online tool to help you manage your
patients enrolled in PROCRITline®.
The portal helps you with:
Efficiency – review the status
of all your PROCRITline® patients online,
and submit enrollment forms electronically
Timeliness – real-time access to patients’
enrollment status and alerts
Flexibility – 24-hour access to
patient accounts
Secure messaging
Register online at www.PROCRITlineProviderESupport.com or call PROCRITline® today.
.com
n easy-to-navigate resource and support site offering many tools such as billing and
A
coding information.
Information about PROCRITline® services and forms
Access to Medicare Local Coverage Determinations (LCDs) in PDF format
Payer guidelines
Sample claim forms
Reference guides to diagnosis codes
Links to useful resources, such as Medicare Carriers and Fiscal Intermediaries,
government agencies, advocacy sites, and clinical sites
PROCRITline
FAQs for physicians
®
Q. How do I obtain a BIF?
A. You can obtain the form by visiting www.PROCRITline.com and downloading an
application. You can also obtain an application by calling PROCRITline at 1-800-553-3851.
If you are a registered user of PROCRITline® Provider eSupport, you may log on to
www.PROCRITlineProviderESupport.com and submit an electronic form.
®
Q. How can I receive a copy of the Summary of Benefits once
a BIF has been submitted?
A. PROCRITline will fax your office a copy of the completed Summary of Benefits.
®
If you are a registered user of PROCRITline® Provider eSupport, you may log on to
www.PROCRITlineProviderESupport.com and view the Summary of Benefits online.
Q. Where can I find updates regarding coverage for Medicare?
A. Updates regarding Medicare coverage for PROCRIT (epoetin alfa) can be found
®
at www.PROCRITline.com or by calling PROCRITline at 1-800-553-3851.
®
Q. Is there someone who can explain the benefits to me?
A. Yes. You can reach out to your PROCRITline® Site Coordinator to discuss the
benefits and answer reimbursement-related questions.
Q. Can PROCRITline provide assistance regarding insurance denials?
A. Yes. PROCRITline can review the Summary of Benefits and denied claims
®
®
to help you understand denials. PROCRITline can also help you with the Exceptions
and Appeals process to help your patient receive coverage for PROCRIT .
®
®
Q. Is there any assistance if a patient has insurance but cannot afford
the co-pays, co-insurance, or deductible?
A. PROCRITline can provide you with information regarding alternate sources of
®
funding such as co-pay foundations. For a comprehensive list of affordability options,
visit http://www.janssenprescriptionassistance.com/PROCRIT-cost-assistance.
Patient insurance benefit investigation is provided as a service by The Lash Group, Inc., under contract for Janssen Products, LP. In
this regard, The Lash Group, Inc., assists healthcare professionals in the determination of whether treatment could be covered by the
applicable third-party payer based on coverage guidelines provided by the payer and patient information provided by the healthcare
provider under appropriate authorization following the provider’s exclusive determination of medical necessity. This reimbursement
support service has no independent value to providers apart from the product and is included within the cost of the product.
Importantly, insurance verification is the ultimate responsibility of the provider. Third-party reimbursement is affected by many factors. This
document is presented for informational purposes only and is not intended to provide reimbursement or legal advice and does not promise
or guarantee coverage, levels of reimbursement, payment, or charge. Similarly, all CPT® and HCPCS codes are supplied for informational
purposes only and represent no promise or guarantee that these codes will be appropriate or that reimbursement will be made. It is not
intended to increase or maximize reimbursement by any payer. Laws, regulations, and policies concerning reimbursement are complex
and are updated frequently. While we have made an effort to be current as of the issue date of this document, the information may not be as
current or comprehensive when you view it. We strongly recommend you consult with your counsel, payer organization, or reimbursement
specialist for any reimbursement or billing questions. While The Lash Group, Inc., attempts to provide correct information, they and
Janssen Products, LP, make no representations or warranties, expressed or implied, as to the accuracy of the information. In no event
shall The Lash Group, Inc., Janssen Products, LP, or their employees or agents be liable for any damages resulting from or relating to the
service provided. All providers and other users of this information agree that they accept responsibility for the use of this service.
Please click here to read the Prescribing Information, including Boxed Warnings and MEDICATION GUIDE, for
PROCRIT® (epoetin alfa).
Janssen Products, LP
© Janssen Products, LP 2014
11/14
021161-140910