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.

2 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.

3 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!

4 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.

5 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.

6 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.

7 Address: City: State: Zip: Phone: Fax: Contact(s): Email: TIN: Billing NPI: BCBS: Other: Additional Facility Information (if applicable) Trial Perm Inpatient Hospital Outpatient Hospital ACS Facility: Address: City: State: Zip: Phone: Fax: Contacts: Email: TIN.

8 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

9 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.

10 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.