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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.
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