Having the right form can help expedite the reimbursement process. Below you’ll find all the forms you need for obtaining verification, ordering Synvisc-One^® or SYNVISC^® (hylan G-F 20) and submitting claims, plus letter templates you can use to confirm prior authorization or request appeals.

Claim Forms

Office Setting
Physicians who administer Synvisc-One and SYNVISC in the office use this claim form to bill Medicare and most other payers.

• Sample CMS-1500 Claim Form (PDF)
• Blank CMS-1500 Claim Form (PDF)

Hospital Setting (Outpatient)

Physicians who administer Synvisc-One and SYNVISC in the outpatient setting use this form to bill Medicare.

• Sample CMS-1450 or UB92 Claim Form (PDF) 
• Blank CMS-1450 or UB92 Claim Form (PDF)

Sample Letters

Sample Medical Necessity Letter

Some insurers may require written confirmation that a patient has knee pain due to osteoarthritis and has failed to respond to conventional therapies.

• Sample Medical Necessity Letter (DOC)

Sample Appeal Letter

This letter template may be used to help you begin the appeals process for a denied claim. 

• Sample Appeal Letter (PDF)

Additional Forms

Insurance Verification

Verify a patient’s unique coverage and reimbursement with SYNVISC Connection. 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 (PDF)

Clean Claims Program

SYNVISC Connection offers comprehensive claim support for your patients. Whether you need us to review a claim, track a claim, or if your patient has received Synvisc-One and the claim was been denied or underpaid, our Regional Appeals Specialists are here to help. If you need claim support, complete the Clean Claims Request form and fax it to 1-800-508-8083.

• Clean Claims Request Form (DOC)