close


close
SYNVISC packaging
genzyme corporationresearchgenzyme websites
Information for patientsContact Us
HomeAbout SYNVISCClinical Info and ResearchReimbursement ResourcesOrdering SYNVISCPatient Education
SYNVISC

Forms & Sample Letters

Having the right form can help expedite the reimbursement process. Below you'll find all the forms you need for obtaining verification, ordering SYNVISC®, and submitting claims, plus letter templates you can use to confirm prior authorization or request appeals.

Claim Forms & Sample Letters

    Insurance Verification
    SYNVISC ConnectionSM can help you verify your patients' unique coverage and reimbursement requirements for SYNVISC. If you would like to use this service, complete an Insurance Verification Request Form, and fax it to 1-800-508-8083 for insurance assistance, including clean claims support.
  • Insurance Verification Request Form (Word, 67K)
    Sample Letters

    Sample Prior Authorization Letter
    Some insurers will not cover SYNVISC without prior authorization.
    SYNVISC Connection can help you verify your patient's insurance-specific requirements. Call 1-800-982-8292 weekdays from 9am to 6pm (EST).
  • Sample Prior Authorization Letter (Word, 30K)
    Sample Medical Necessity Letter
    Some insurers may require written confirmation that a patient has knee pain due to osteoarthritis (OA), and has failed to respond to conventional therapies.
  • Sample Medical Necessity Letter (Word, 32K)
    Sample Appeal Letter
    This letter template may be used to help you begin the appeals process for a denied claim.
  • Sample Appeal Letter (Word, 42K)

Return to top

Specialty Pharmacy Order Forms

If you have patients whose insurers require them to order SYNVISC through Specialty Pharmacies, you may do so using one of these forms. If the form you are looking for is not listed below, please contact the patient's specific insurance company.

The reimbursement material provided represents the current understanding of Genzyme. Many of the topics covered in this guide are complex and all are subject to change beyond Genzyme's control. Healthcare delivery professionals are responsible for keeping current and complying with reimbursement policy and regulations. This information is not intended to be directive, nor does the use of the recommended codes guarantee reimbursement. Providers should select the codes that most accurately reflect the patient's medical condition, payer requirements, practice patterns, and services rendered. Providers also are responsible for the accuracy of any claims, invoices, and related documentation submitted to payers.

Return to top




Important Safety Information

SYNVISC® (hylan G-F 20) is indicated for the treatment of pain in osteoarthritis (OA) of the knee in patients who have failed to respond adequately to conservative nonpharmacologic therapy and simple analgesics, e.g., acetaminophen. In clinical trials, the most commonly reported adverse events were transient local pain, swelling, and/or effusion in the injected knee. In some cases, these symptoms have been extensive. Other side effects such as rash have been reported rarely.

SYNVISC is contraindicated in patients with known hypersensitivity to hyaluronan products or patients with infections in or around the knee. Use caution when using SYNVISC in patients allergic to avian proteins, feathers, or egg products; who have evidence of venous or lymphatic stasis in the leg to be treated; or who have severe inflammation in the knee joint to be treated. Patients should be advised to avoid strenuous or prolonged weight-bearing activities after treatment. Strict adherence to aseptic technique must be followed to avoid joint infection. The safety and effectiveness of SYNVISC in children and in pregnant or lactating women have not been established. It is unknown whether SYNVISC is excreted in human milk.

View the Complete Prescribing Information for SYNVISC (PDF, 146k)