Medicare
Medicare typically covers and reimburses SYNVISC® in both the physician's office and hospital
outpatient settings when the patient has documented knee pain due to osteoarthritis (OA), and has failed to respond to conventional therapies.
Medicare does not require prior authorization.
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SYNVISC is covered according to specific local coverage determinations (LCDs) that have been established by the regional Medicare carrier, and when administered "incident to" a physician's care.
This means SYNVISC must:
- Be provided by and represent a cost to the physician, and
- Be administered in the physician's office by a physician or someone under the physician's supervision.
For billing instructions in the office setting:
Download the Sample CMS-1500 Claim Form (PDF, 225K).
Download more Forms & Sample Letters, including a Blank CMS-1500 Claim Form (PDF, 87K)
Competitive Acquisition Program (CAP)
The CAP is an optional program offered to physicians who do not wish to stock commonly billed drugs and biologics, such as SYNVISC, given in the physician office for Medicare patients. Instead, physicians may enroll in this program and order all CAP products exclusively through the CAP specialty vendor, BioScrip. CAP physicians no longer buy and bill for CAP products, except for emergent use or under special circumstances. CAP enrollment is offered annually. Once enrolled, CAP physicians bill their local Medicare carrier for the administration only. All Medicare Part B carrier local coverage decisions (LCDs) apply to SYNVISC administration and claims made through CAP.
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In the hospital outpatient setting, Medicare coverage is subject to the same general criteria, modified as follows:
- Services are reimbursed under the Medicare hospital outpatient prospective payment system (OPPS), using ambulatory payment classifications (APCs) that map procedures to fixed payment amounts.
- A single hospital outpatient visit may qualify for multiple APC payments.
- Under the Medicare OPPS, the hospital outpatient department acquires and bills for SYNVISC and its related administration services.
- Medicare reimburses hospitals for SYNVISC and related administration services using unique APC payment amounts.
- In addition, physicians bill for their professional services and receive separate reimbursement for the administration on a separate Blank CMS-1500 Claim Form (PDF, 87K).
For billing instructions in the hospital outpatient setting:
Download the Sample CMS-1450 or UB92 Hospital Claim Form (PDF, 15K).
Download more Forms & Sample Letters including a Blank CMS-1450 or UB92 Claim Form (PDF, 17K).
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Medicare Advantage Plans
Medicare offers managed care insurance, known as Medicare Advantage (MA) plans, as an alternative to traditional Medicare Part B coverage. MA plans are administered by commercial insurers, and provide the scope of benefits offered under Part B, as well as supplemental benefits, such as coverage of Medicare premiums and deductibles, or prescription drug coverage. MA plans serve one or more entire regions, and have a network of contracted providers offering benefits at a uniform premium and level of cost-sharing to all Medicare beneficiaries residing in the MA plan service area. It is important to confirm your patient's specific MA plan benefits to understand coverage and reimbursement requirements for SYNVISC.
Questions about Medicare coverage?
SYNVISC ConnectionSM is staffed with a team of reimbursement specialists
who can help you understand Medicare coverage and payment requirements for SYNVISC. You can reach SYNVISC Connection at 1-800-982-8292, M-F, 9am-6pm (EST).