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PRESCRIBING INFORMATION


CONTACT US

Phone Number (800) 44-BOTOX, Option 4

Monday through Friday
9:00am- 8:00pm ET
Address
Botox®
PO Box 220350 
Charlotte, NC 28222-0350

Your Provider Resource Center for Service and Information Relating to BOTOX® Reimbursement
Click here to see Important Information about Botox (onabotulinumtoxinA)

Resources

Useful Links for your Reimbursement Needs


Billing Guide

Six Easy Steps to the BOTOX® Billing Process

Conduct an Insurance Verification for Primary and Secondary Payers, as applicable
The term "insurance verification" is used to describe the process whereby a patient's payer is contacted to find out all the details related to the patient's policy and its coverage for BOTOX® treatment and related services. It is through an insurance verification that providers learn whether the payer requires a prior authorization for BOTOX®, as well as other benefit information, such as any limitations or restrictions, co-payments, and deductibles.

Determine the Submission and Documentation Requirements for the Prior Authorization, if Applicable
The term "prior authorization" is used to describe the process by which a payer requires specific information about a patient's medical condition prior to a service, such as clinic notes, a letter of medical necessity, treatment history, etc, in order to make a coverage determination regarding that service.

Document Medical Necessity, Treatment and Procedures
The documentation of a patient's care is the body of evidence that supports a claim for payment. A letter of medical necessity contains the information needed to document the medical necessity for the BOTOX® injection.

Complete Charge Sheet with Appropriate Payer Codes for Billing the BOTOX® Claim
To complete the Charge Sheet, the provider should review the payer's coding guidelines for specific coding requirements. The BOTOX® Reimbursement Solutions Hotline is also available to assist you in determining a specific payer's requirements.

Submit Claim to Primary and/or Secondary Payer for Processing
Co-payments and co-insurance are important components of reimbursement. It is important for providers to make a good faith effort to consistently bill and collect from all patients for their cost-sharing responsibility. Further, in addition to billing a patient's primary payer, it is critical that providers bill secondary and/or supplemental payers, when applicable.

Receive Payment from Payer and Reconcile Claim
After claim submission, you should receive payment or notification on the claim along with an Explanation of Medical Benefits (EOMB). If you file electronically, you may receive payment information within two to three weeks. If at this time you receive a denial or underpayment, the BOTOX® Reimbursement Solutions Hotline can help you appeal. The hotline can also assist with tracking the status of your claim, per your request.

Reasons for Claim Denial

Most Common Reasons for Claim Denials

Why are Claims for Reimbursement Denied or Underpaid?

Three basic requirements must be met before any payer will accept and pay a claim for medical services:

  • Services must be medically necessary as documented through coding or by materials submitted from the patient's record.
  • Billing must comply with the payer's standards, rules, and regulations.
  • Claim forms must be properly completed.

If one or more of these requirements is not fully met, the payer will typically identify the specific reason(s) for the claim denial, either in the denial letter itself, on the Explanation of Medical Benefits (EOMB) or on the Medicare Summary Notice (MSN) form.


The five most common reasons for denial or underpayment are:
  1.  Incomplete or missing information on the claim form
  2.  Incorrect or inappropriate use of an ICD-10 diagnosis, CPT procedure code, or HCPCS code for BOTOX® treatment
  3.  Incorrect or inappropriate use of modifiers
  4.  Failure to observe the payer's exact requirements for coverage
  5.  Failure to correctly specify the amount of drug used

How to Appeal a Denied or Underpaid Claim

Payers will accept rebilled and appealed claims for a specified period after service is performed. This time limit may vary by payer. Each payer has its own appeals process, usually described in the payer's contract. In all cases, an appeal will involve careful examination of all information submitted concerning the denied claim. The following steps describe the general process for preparing an appeal.

Determine the reason for denial or underpayment.

Confirm

  • Does the Explanation of Medical Benefits (EOMB) explain the denial?
  • Is any information missing?
  • Has the claim been signed?
  • Do all charges on your CMS 1500 or UB-04 appear on the EOMB?

Verify the payer's appeals process and prepare an appeals strategy.

 

Consider

  • Can you save time and increase cost-effectiveness by refiling the claim rather than appealing it?

Assemble the appeals materials (EOMB, payer coverage policy, documentation of medical necessity).

Prepare

  • A letter introducing your appeal
  • A letter of medical necessity

Submit your appeal.

Follow-up

  • Check with the payer in 7 days to determine the status of your appeal.

Disclaimer
For more details about the appeals process contact the BOTOX® Reimbursement Solutions Hotline at (800) 44-BOTOX, Option 4.

The BOTOX®
Guide to Billing and Claims Appeal Procedures is provided as information only. While every attempt is made to provide up-to-date information, Allergan does not ensure the accuracy of the information provided. Since third-party reimbursement is affected by many factors Allergan makes no representation or guarantee that you will be successful in obtaining insurance reimbursement and other payment.

Medicare Part B Claim Appeals Process

The guidelines listed below are specific to the Medicare appeals process. Note that each payer will have a different process for responding to an appeal and you should request information on the appeal process used by the specific payer for each claim. The BOTOX® Reimbursement Solutions Hotline at (800) 44-BOTOX, Option 4 can help you obtain information about payer appeals processes.

Steps in the Medicare Part B Claim Appeals Process

Inquire about a denied or underpaid claim by telephone after you receive the explanation of Medical Benefits (EOMB) form. The steps necessary to correct problem claims are usually easy to determine and the claim can often be resubmitted rather than formally appealed. Medicare will allow for claim resubmission up to 12 months after the service is performed.

If you cannot determine the reason for denial, or you disagree with the rationale for denial or underpayment, you can appeal the claim by filing a Redetermination (First Level of Appeal). The time limit for filing an appeal is 120 days after the original EOMB date.

MACs generally issue a decision within 60 days of receipt of the request for redetermination.

You will receive notice of the decision via a Medicare Redetermination Notice (MRN) from your MAC or, if the initial decision is reversed and the claim is paid in full, you will receive a revised Remittance Advice (RA).

If you disagree with the MAC redetermination decision, you may request a Reconsideration (Second Level of Appeal) by a Qualified Independent Contractor (QIC). You must file a request for reconsideration within 180 days of receipt of the MRN or RA. File your request in writing by following instructions provided on the MRN or RA. You may also file a request for reconsideration by completing Form CMS-20033.

Generally, a QIC sends a decision to all parties within 60 days of receipt of the request for reconsideration.

If you disagree with the reconsideration decision or wish to escalate your appeal because the reconsideration period has passed, you may request an Administrative Law Judge (ALJ) hearing (Third Level of Appeal). You must file a request for an ALJ hearing within 60 days of receipt of the reconsideration decision letter or after the expiration of the reconsideration period. File your request in writing by following instructions provided in the reconsideration letter. You may also request an ALJ hearing by completing Form CMS-20034 A/B.

You may only request an ALJ hearing if a certain dollar amount remains in controversy following the QIC's decision. The Amount in Controversy (AIC) threshold is updated annually.

Generally, if the ALJ decision overturns the previous denial in whole are in part, the MAC must pay the claim within 30-60 days. If you disagree with the ALJ decision, or you wish to escalate your appeal because the ALJ ruling timeframe passed, you may request a Medicare Appeals Council Review (Fourth Level of Appeal). You must file your request for Medicare Appeals Council Review by completing Form DAB-101.

Generally, the Appeals Council issues a decision within 90 days from receipt of a request for review of an ALJ decision.

If you disagree with the Appeals Council decision, or you wish to escalate your appeal because the Appeals Council ruling timeframe passed, you may request Judicial Review in U.S. District Court (Fifth Level Appeal). You must file a request for judicial review within 60 days of receipt of the Appeals Council's decision or after the Appeals Council ruling timeframe expires.

You may only request a judicial review if a certain dollar amount remains in controversy following the Medicare Appeals Council decision. The Amount in Controversy (AIC) threshold is updated annually.

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The information on this site is intended for US healthcare providers only.
No information in this site is provided with the intention to give medical advice or instructions on the accurate use of Allergan products.
Allergan cannot answer unsolicited e-mails requesting personal medical advice; visitors should always consult a healthcare professional.