Billing Information for Healthcare Professionals
Billing Information Sheet
We want you to be able to focus on the care of your patients, and to leave the insurance process to us. We are committed to doing all we can to help your patients manage any expenses related to our tests.
Biotheranostics believes every clinically eligible patient should have access to our tests, independent of their insurance or financial status. We accept all insurance plans and offer a robust patient assistance program for patients in need.
This process starts with ensuring your patient's complete insurance information is provided on the Biotheranostics test requisition prior to sending it in to us.
We then contact the pathology departmentto have the specimen sent for testing. Afterthe test is performed by us, the results aredelivered to the ordering physician.
We bill the patient's insurance company.Biotheranostics Patient Advocates areavailable to discuss the billing process andoptions that may be available to your patientsto help manage any out of pocket expenses.
The billing process will take several monthsand during this time your patient will receivea communication from the insurancecompany called an Explanation of Benefits(EOB). This is NOT A BILL.
In addition to the EOB from the insurance company, your patient will receive a welcome letter from Biotheranostics that outlines our billing and appeals process and contains an important document that they will need to sign and return to us. This Authorization of Representation form allows us to appeal to insurance companies on a patient's behalf.
The insurance company will send payment to us for the test. Your patient may be responsible for a deductible, co-payment, and/or co-insurance as indicated by the insurance plan and required by federal/state regulations. Our Patient Assistance Program is designed to help manage these out of pocket expenses and is based on household income and financial responsibilities.
IF YOUR PATIENT IS A MEDICARE BENEFICIARY
Medicare accepts CancerTYPE ID® and Breast Cancer IndexSM as medically necessary and covers the tests at a predetermined rate with no fees charged to the patient when specific criteria are met under a local coverage determination (LCD). See reverse side for details. In most cases Medicare will be billed directly. However, in certain situations with CancerTYPE ID® we are obligated to bill the hospital; the “14 Day Rule” is a regulation set by the Centers for Medicare and Medicaid Services (CMS) that requires laboratories, including Biotheranostics, to bill the hospital for clinical laboratory services and the technical component of pathology services provided to Medicare patients when services are ordered less than 14 days after the patient was discharged.
IF YOUR PATIENT IS INSURED BY COMMERCIAL INSURANCE
We accept all insurance plans, and are currently in network with a growing number of plans. In the event your insurance company sends payment to your patient, please have your patient forward the check to us. If an insurance company denies coverage, we will work on behalf of the patient to attempt to obtain coverage and will assist in pursuing any appeals on the patient's behalf.
IF YOUR PATIENT DOES NOT HAVE INSURANCE
Biotheranostics will bill patients directly for services ordered. Please inform you patients that they can apply for assistance through our Patient Assistance Program or Payment Plan.
PATIENT ASSISTANCE PROGRAM
Our robust Patient Assistance Program can help lower the bill for patients. This requires patients to provide a paystub, W-2 or other documentation of income.
We offer a discounted “direct pay” price for patients who wish to pay cash for our testing. We offer a 6 month interest free payment plan option for patients who need to make payments in installments.
To discuss our Patient Assistance Program and eligibility requirements, contact our Patient Advocate Team at 1(877) 886-6739, select prompt 2.
MEDICARE LOCAL COVERAGE DETERMINATION(LCD) CRITERIA:
CancerTYPE ID is covered as a once-in-a-life time benefit. The assay may be used to resolve an unknown primary tumor or to resolve a pathological diagnosis with 2 or more differential diagnoses. In the unlikely event of a second UPC, denied claims can be appealed through standard Medicare protocol.
Use of the CancerTYPE ID assay is limited to:
- Tumors for which a single specific site of origin has not been established or resolved by the combination of clinicopathologic studies and consultation with pathologists, radiologists and oncologists.
- Specimens, such as cytology cell blocks, where limited quantity of the specimen precludes standard pathologic workups
Breast Cancer IndexSM (BCI)
Coverage of the Breast Cancer Index (BCI) is limited to patients that meet the following criteria:
- Post-menopausal female with non-relapsed, ER+ breast cancer, and
- Was lymph node negative (LN-), and
- Is completing five (5) years of tamoxifen therapy, and
- Patient must be eligible for consideration of extended endocrine therapy based on published clinical trial data or practice guidelines, and
- Physician or patient is concerned about continuing anti-hormonal therapy because of documented meaningful toxicity or possible significant patient-specific side effects, and
- The test results will be discussed with the patient (including the limitations of the testing method, the risks and benefits of either continuing or stopping the therapy based on the test, and current cancer management guidelines).