This form authorizes AB Insurance Reimbursement Services to act as your representative and on your behalf to secure all authorization necessary from your insurance company regarding a procedure or order involving an AB medical device, including, if necessary, any appeal of a denial of benefit and in billing to your insurance carrier for replacement parts, if necessary.

Advanced Bionics respects the privacy of all of our customers, and we will not utilize your personal and insurance identifying information for any purpose other than treatment or payment. If we want to use your information for any other purpose outside of treatment and payment, this will require a written authorization specific for that use directly from you. If you have additional questions concerning HIPAA, please email HIPAA@advancedbionics.com.

Prior to verifying your health plan benefits, we must have this healthcare provider’s order form completed on file.

Some health plans require pre-authorization of cochlear implant surgery and replacement supply orders(s). Pre-authorization or pre-approval is a process that some health plans use to ensure that a procedure, service, or supply is medically necessary prior to treatment. Depending on your health plan, the pre-authorization process can take between five and 30 business days.

After our Reimbursement Specialists perform the required benefits verification and applicable pre-authorization your order will be shipped. We will then submit a claim to your health plan for payment consideration. Upon receipt of the claim, your health plan will take up to 15 to 30 business days to process it. They will send you their payment decision in the form of an Explanation Of Benefits form (EOB), which shows the supplier’s charge, the allowed amount, the payment or denial, and the patient’s financial responsibility. In cases where coverage is considered out of network or denied, we will assist you with the appeal process.

Our Reimbursement Services and Insurance Authorization team provides support for both assigned and non-assigned claims.

Advanced Bionics can provide appeals assistance for you and your cochlear implant center when there is difficulty in obtaining approval for the cochlear implant surgery or cochlear implant replacement supplies from your health plan.

Upon request, our Reimbursement Services Specialists will review the reasons for non-coverage of a claim for your replacement supplies and equipment. Many times these denials are related to the health plan’s misclassification of cochlear implant supplies as hearing aids, and they will require further clarification for reprocessing your claim appropriately.

Please contact one of our Reimbursement Specialists to discuss your particular situation so that we can provide you the appropriate level of assistance.

Medicare is a federal program that provides specific health benefits to individuals who are 65 years of age or older, and/or are permanently disabled persons who are under the age of 65, and for children who receive transplants. Cochlear implant supplies and replacement equipment are covered under Medicare Part B. Medicare does not require pre-authorization for cochlear implant surgery or related supplies as long as the patient meets medical criteria. Part B has a monthly premium that changes annually and typically is deducted from the beneficiary’s Social Security payment. Part B also has an annual deductible and 20% co-insurance, as described above. Medicare Advantage and HMO plans are not the same as traditional Medicare, and they typically require pre-authorization for cochlear implant services. Learn more about Medicare terminology.

TITLE XIX of the Social Security Act is a federal/state entitlement program that pays for medical assistance for certain individuals and families with low incomes and resources. Each state legislative branch allocates a portion of the budget on a yearly basis. As such, they have considerable latitude in determining what services they will provide. Many states will cover procedures paid by Medicare, including cochlear implantation, but they typically require pre-authorization for cochlear implant surgery and related supplies. Under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) provisions of the Medicaid law, states are required to cover cochlear implantation for children (age 12 months through 18). Please contact one of our Reimbursement Specialists to determine if Advanced Bionics is a participating provider for your state Medicaid plan.

HMO members must receive their medical services and supplies from physicians, facilities, and suppliers within the HMO network to receive benefits, unless an exception is approved. HMOs may require a referral authorization from the primary care physician (PCP) to the supplier. In addition to a referral authorization, the plan may require a separate authorization for services and supplies.

These plans have coverage for both in-network and out-of-network benefit levels and they usually do not require pre-authorization for cochlear implantation and related replacement supplies. Members may also receive services and supplies from providers or suppliers outside the network, but different benefits may apply.

Make sure AB has your most recent insurance information on file. We must have the completed forms before we can verify your health plan benefits, provide authorization support if applicable, or billing a claim to your health plan. Based on your healthcare requirements, you may be required to provide credit card information at the time of your order and/or at the time of pre-authorization for your co-insurance and/or deductible responsibility.

Place your order for replacement supplies and equipment with AB’s Customer Service. We may be required to place your order on hold until our Reimbursement Specialist obtains authorization from your health plan for your supplies. This means that your credit card will not be charged until we obtain authorization and contact you regarding any applicable co-insurance or deductible for which you may be responsible.

If pre-authorization is a requirement under your plan, your order(s) will be placed on hold until our Reimbursement Specialist obtains approval for your supplies. Once we obtain the appropriate approval, we will collect any applicable deductible or co-insurance required by your health plan.