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Provider Billing Guide

Step 1: Prepare Claim Step

The below items must be submitted to be reimbursed for services rendered:

· A complete W-9 form is required in order to process reimbursement requests for payment. If this is the first patient from
  your practice to be approved for assistance, a W-9 form has been attached to this guide for your convenience.

· Medications treating the patient’s disease state are covered by the Patient Access Network (PAN). A CMS-1500 form with
  the corresponding explanation of benefits (EOB) is required for physician billing and a UB-04 with the corresponding
  explanation of benefits (EOB) is required for hospital billing.

· Dates of service should be itemized to show the actual date the patient received the drug.


What services will be reimbursed?

Physician administered products

- PAN will reimburse co-payments, coinsurances, and/or deductibles related to eligible medications after the patient’s
  primary insurance has considered those same medications for payment. Medical services such as lab work, office
  visits, or *administration are not covered by PAN.

- Eligible medications paid by the primary payer at 100% of the contracted rate cannot be reimbursed by PAN.

Pharmacy

- PAN will reimburse co-payments, coinsurances, and/or deductibles related to eligible medications after the patient’s
  primary insurance has considered those same medications for payment.

- Drug discount cards are not considered insurance, therefore, charges remaining after discount taken with drug
  discount cards are not considered co-payments and are not reimbursable.

- Pharmacy label showing co-pay and drug name or a pharmacy invoice showing the drug name and amount, primary
  insurance payment, and patient responsibility.


Step 2: Submit Claim

When should I submit for reimbursement?

· The patient is allowed a 90-day look-back period from the eligibility begin date to allow for payment charges incurred
  prior to the initial approval. The 90-day look-back period applies only to the first year of
  eligibility.

· A patient’s grant may be discontinued 60 days after the eligibility begin date if no requests for reimbursement have been
  received.

· There is a claims filing limit of 120 days after the eligibility end date to allow adequate time for claims submissions for
  dates of service within the patient’s eligibility period.

How do I submit for reimbursement?

· Claim forms and EOBs can be faxed to (866) 316.7261 or

· Mailed to:      Patient Access Network

                          PO Box 221858

                          Charlotte, NC 28222-1858


Step 3: Receive Reimbursement

When will we receive reimbursement?

· Amounts greater than $100 will be reimbursed in less than 10 business days.

· Amounts totaling less than $100 will be reimbursed after 30 days.

· Amounts $5 or less are not reimbursable unless subsequent requests are received that would increase the payment
  amount to more than $5.


Click here to download PDF with full explanation
.