Quick Start To Spinal Cord Stimulation Pre-Authorization 3 ...

1 Provider Intake Form HIPAA & Consent Agreement The business agreement outlines our obligation to safeguard your patients health information. When health information is provided to us, the agreement begins. Go to: and click on HIPPA Agreement. 22 11 We are your advocate in facilitating patient access to SCS in collaborating with payers to assist you and your patients with the Pre-Authorization process. After completing the easy three step process below, Boston Scientific Neuromodulation s Pre-Authorization Department is able to assist with your requests in securing SCS pre-authorizations for your patients. 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.

2 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. Reimbursement Hotline: (866) 287-0778 Quick Start To Spinal cord Stimulation Pre-Authorization On-Board Call 33 This form requests physician and facility demographic information including, provider locations, NPI numbers, TIN numbers, Fax Form to BSC Review Online Fax Completed Provider Intake Form to 1-877-835-2520 Neuromodulation Get Started Today!

3 BSC Will Call You 1 All documents are available on our website 3-200944 Please check the box at the bottom of the Provider Intake Form if you would like an On-Board Call, where a BSC Reimbursement Specialist will review the Pre-Authorization process with you and your staff. Provider Intake Form Complete and return via fax 1-877-835-2520 Email to: Neuromodulation 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.

4 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. Sales Rep Name: Phone: CS Name: Phone: Territory: IMPORTANT: If you would like an On-Board Call where your Reimbursement Specialist will give you an overview of BSC s Pre-Authorization process, please check the box and a BSC Reimbursement Specialist will contact you. Thank you! Physician Information Physician: Practice Name: Address: City: State: Zip: Phone: Fax: Contact(s): Email: TIN: Billing NPI: Doctor NPI: BCBS: Medicaid: UPIN: ACS: Other: Trial in Office: Yes No Please Provide Facility Information Below Facility Information Trial Perm Inpatient Hospital Outpatient Hospital ACS Facility: Address: City: State: Zip: Phone: Fax: Contact(s): Email: TIN: Billing NPI: BCBS: Other.

5 Additional Facility Information (if applicable) Trial Perm Inpatient Hospital Outpatient Hospital ACS Facility: Address: City: State: Zip: Phone: Fax: Contacts: Email: TIN: Billing NPI: BCBC: Other: Comments Boston Scientific Internal Use Only - SCS Sales Representative Information: 3-200945 Pre-Authorization Form Instructional LetterNeuromodulationHealth 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.

6 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. The PRECISION Spinal cord Stimulator System (Precision System) is indicated as an aid in the management of chronic intractable pain of the trunk and/ or limbs, including unilateral or bilateral pain associated with the following: failed back surgery syndrome, intractable low back pain, and leg pain.

7 Should you have any questions, please call our Reimbursement Services Department at 1-866-287-0778. We are available to assist you Monday through Friday from 6:00am to 5:00pm, Pacific Time. Thank you! Please thoroughly complete each row in this section. Note: enter physician s NPI # and TIN#. Please check applicable box for the principal diagnosis (P) and any supporting secondary diagnosis (S) codes. If the principal diagnosis code is not listed, please write in the diagnosis in the other section. Check applicable box(es) and enter number of units. Code L8680 is for per contact/ electrode. Check applicable box(es) and enter number of units. If revision, replacement or removal procedure please specify the type of procedure in detail via the notes section. Physician must complete or review, sign and date the Pre-Authorization form.

8 Clinical documentation ( , treatment history & pysch. eval.) and patient insurance information must be included. Please fax completed Pre-Authorization form and all requested documentation information to completed form to 1-877-835-2520 Dear Valued Boston Scientific Customer, Please use the attached Pre-Authorization Form for submissions of Precision Plus Spinal cord Stimulator (SCS) Pre-Authorization requests. The Pre-Authorization form provides you with an easy check-the-box format to help facilitate a Quick and easy process. This form will provide us important patient and procedure information including diagnosis and procedure codes for SCS trial and permanent Pre-Authorization requests. The diagnosis code list is not an exhaustive list, but is a list of codes that relate to the indication statement below for the Precision SCS System.

9 SCS coverage criteria and diagnosis codes vary by payer, and it is always the physician s responsibility to determine appropriate diagnosis codes based on medical necessity. Boston Scientific does not guarantee reimbursement coverage and the ultimate responsibility for obtaining reimbursement rests with the provider. Instructions For Completing The Pre-Authorization Form: Section 1 Section 2 Section 3 Section 4 Section 5 3_200989 Pre-Authorization Form Patient s Full Name: Patient s DOB: Physician Name: Name of Surgery Site: Surgery Date: State: NPI# TIN# Site of Surgery: Physician Office ASC Outpatient Hospital Inpatient Hospital Procedure Type.

10 Trial Permanent Implant Revision/ Replacement* Removal* Diagnosis Code SectionPrincipal Diagnosis Code: Please indicate the principal (P) and secondary (S) diagnosis by checking the appropriate box: P = Principal and S = Secondary. If the principal diagnosis code is not listed below, manually enter the code and description into the other section(s) at the bottom right of this Diagnosis Code Section. sympathetic dystrophy, unspecified or lumbar spondylosis with myelopathy, thoracic region or lumbosacral neuritis or radiculitis, unspecified sympathetic dystrophy of the lower limb or lumbar spondylosis with myelopathy, lumbar region , neuritis, and radiculitis, unspecified sympathetic dystrophy of other specified site intervertebral disc without myelopathy in limb pain or lumbosacral intervertebral spondylolisthesis pain due to trauma disc disorder with myelopathy, lumber region to nerve roots and Spinal plexus, dorsal root chronic postoperative pain syndrome, lumbar to nerve roots and Spinal plexus, lumbar root chronic pain stenosis, other than cervical/unspecified region of lower limb stenosis, other than cervical/throacic region of lower limb, unspecified stenosis.