Insurance Intake Form, Authorization and Assignment of Benefits

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1 Recipient Information Insurance Intake Form, Authorization and Assignment of Benefits Return completed and signed form with copies of insurance card(s), front and back, to: Fax: (303) Recipient Name: Date of Birth (mm/dd/yyyy): Sex: Male Female Parent/Guardian (if applicable): Address: City: State: Zip: Day Phone: Alternate Phone (optional): Address: Fax (optional): Emergency Contact Name (not living at above address): Emergency Contact Phone: Clinic Information Clinic Name: Surgeon: Audiologist: Contact Person: Contact Phone: Primary Insurance Carrier (Complete all that apply) Insurance Company Name: Address (from card): City: State: Zip: Phone: Group Plan No: Member Name: ID #: Member Date of Birth: Relationship to Recipient: Secondary Insurance Carrier (Complete all that apply) Insurance Company Name: Address (from card): City: State: Zip: Phone: Group Plan No: Member Name: ID #: Member Date of Birth: Relationship to Recipient: Primary Care Physician Information Primary Care Physician Name: Address: City: State: Zip: Phone: Return this completed and signed form to: Cochlear Americas, E. Peakview Avenue, Centennial, Colorado Phone: (800) Fax: (303) Page 1 of 2 Version 4/13/09

2 Insurance Intake Form, Authorization and Assignment of Benefits Authorization and Assignment of Benefits Release of Medical Information Authorization. I authorize Cochlear Americas Insurance Reimbursement Department to release pertinent information about my medical condition for the purpose of securing health insurance benefits information, authorization or payment for devices or services. I will provide a current copy of any insurance identification cards, policy numbers and demographic information to Cochlear Americas upon request. I also authorize Cochlear Americas Insurance Reimbursement Department to act as my representative and on my behalf to secure all authorization necessary from my insurance company regarding procedures or orders involving a medical device manufactured by Cochlear Americas, including, if necessary, any appeal of a denial of benefit and in billing my insurance carrier for replacement parts. I understand that I may revoke this authorization at any time by giving my physician or Cochlear Americas a statement to withhold my personal and medical information from that time forward. Assignment of Benefits. I request that payment of authorized insurance benefits be made on my behalf to Cochlear Americas for any equipment or services provided to me by Cochlear Americas. I understand and agree that a copy of this authorization and/or assignment of benefits, when signed by me, my authorized representative, or a legal guardian, may be sent to my insurance company or health care provider, if requested. A copy of this authorization and assignment of benefits shall be as valid as an original, and Cochlear Americas may refer to my signature on file regarding this authorization and/or this assignment of benefits. By my signature, or an authorized signature, below, I understand and agree to the following: I am financially responsible to Cochlear Americas for any charges not covered by my health care benefits and for any portion of any charges denied by my health care benefits, in accordance with applicable law; I am responsible to notify Cochlear Americas of any changes in my address and in my health care coverage, and failure to do so may result in delays in processing my order or inability to process my order; In some cases, exact insurance benefits cannot be determined until the insurance company receives the claim and this may delay the processing of my order with Cochlear Americas; Since I am assigning to Cochlear Americas my right to receive payment directly from my insurance company or from Medicare or Medicaid, if I receive payment directly, I agree to reimburse fully Cochlear Americas upon request for the cost of my order(s) and I understand that Cochlear Americas has the right to recover its cost of collection from me if I fail to reimburse Cochlear Americas properly and timely, in this circumstance; I will promptly (within 5 business days) forward all insurance correspondence (such as explanation of benefits and other similar forms or communication) related to my order(s) to Cochlear Americas address below; I acknowledge receiving or viewing online a copy of Cochlear Americas Notice of Privacy Practices; and I understand that Cochlear Americas will endeavor to obtain authorization from my insurance provider to reimburse my healthcare provider or Cochlear Americas for services or items that may be covered. However, there is no guarantee that Cochlear Americas will receive authorization or payment from my insurance provider. Acknowledgment. I understand that Cochlear Americas is a supplier of medical devices and I should rely on my own health care provider for medical advice, diagnosis, and expected outcome of the use of a Cochlear Americas implantable device. Enclosed herewith, I received a copy of the Billing Service Recipient Bill of Rights and Responsibilities, DME POS Supplier Standards, Notice of Privacy Practices and a Billing Service description. I have received the product manual/instructions and warranty information, if applicable. I understand that I may lodge a complaint without concern for reprisal, discrimination or unreasonable interruption of service. I understand that the Billing Service hours of operation are 8:00 am to 5:00 pm MT. If I experience an emergency I should contact my own health care provider. By signing below, I hereby certify that the information I have provided in this form is truthful, correct, and complete, and I understand and agree to the terms of this authorization and assignment of benefits. I acknowledge that any inaccurate information provided in this form or omission of accurate information may delay the processing of my claim and/or my order(s), and/or shall be grounds for Cochlear Americas to cease providing parts, repairs, or service to me. Date: Signature: Name (Please print): Return this completed and signed form to: Cochlear Americas, E. Peakview Avenue, Centennial, Colorado Phone: (800) Fax: (303) Page 2 of 2 Version 4/13/09

3 Cochlear Americas Billing Service Recipient Bill of Rights and Responsibilities The goal of Cochlear Americas Billing Service is to treat our recipients in a dignified and responsive manner and establish a strong relationship with our recipients to show that we are committed to help them meet their ongoing needs associated with their Cochlear products. A part of Cochlear Americas commitment to its recipients, Cochlear Americas currently sells parts and accessories to recipients of its products and also offers assistance with their Medicare/Medicaid billing. To make this service work effectively, there are some things that Cochlear Americas is responsible for and there are some things that each recipient is responsible for. And there are some things that Cochlear Americas has no control over, such as the laws that govern the provision of this service. The following provides some information about Cochlear Americas responsibilities and the recipient s responsibilities. Cochlear Responsibilities. One way in which we hope to reach our goal is to train all employees involved in Billing Services regarding the following recipient rights: 1. The recipient has the right to choose his/her own health care provider. Cochlear Americas provides access to parts, accessories, and services required to maintain function of the recipients Cochlear implantable hearing device. 2. To refuse service after informed consent and the consequences of refusing service are fully presented. 3. To receive a copy of the Cochlear Americas Billing Service Recipient Bill of Rights and Responsibilities and a copy of the Medicare DMEPOS Supplier standards at the start of service. 4. To receive service, parts, accessories and repairs without discrimination as to race, ethnicity, national origin, religion, sex, age, disability or sexual orientation. 5. To receive a copy of Cochlear Americas Notice of Privacy Practices describing ways in which Cochlear may use and disclose Protected Health Information. 6. To be fully informed in advance about the part, accessory or service to be provided and any modifications that may occur. 7. To be represented by a parent, guardian, family member or other conservator if the recipient is unable to fully participate in his or her decisions. 8. To be informed of charges, including payment expected by third parties and any charges for which the recipient will be responsible. 9. To have their property and person be treated with respect, consideration and recognition of their dignity and individuality. 10. To be informed of his or her responsibilities regarding billing Medicare and Medicaid (and, in some cases, commercial health plans) for medically necessary parts and repairs. 11. To voice grievances or complaints regarding service and to have the complaints investigated and resolved in a timely manner. Recipient Responsibilities. Recipients with Cochlear Americas products who order external parts, accessories and repairs are responsible to Cochlear Americas for the following: 1. To have necessary Medicare, Medicaid or commercial health plan insurance billing information at the time of order. 2. To provide additional documentation, if necessary to complete an order, in a timely manner. 3. To discuss their concerns with the Cochlear Americas representative when they lack a clear understanding of Medicare, Medicaid or commercial health plan benefits covering parts and repairs of Cochlear Americas external products and what may be expected of them. 4. To pay their financial obligations associated with the purchase of parts and repairs, including co-payments and fees for non-covered services, in a timely manner. 5. To use their health plan benefits in an honest and ethical manner. 6. To work with their professional caregiver to facilitate adherence with federal, state and Cochlear Americas referral procedures and to provide proper and necessary authorization for parts and repairs needed. 7. To respect loaned sound processors and other equipment, and return the loaned equipment in good working condition and in a timely manner 8. To inform Cochlear Americas in the event of changes to name, address or health insurance status. BSD002 Iss1 FEB09

4 A SERVICES DESCRIPTION OF COCHLEAR AMERICAS BILLING SERVICE In 1995, Cochlear Americas established the Billing Service as part of ongoing company efforts to provide comprehensive customer service to recipients of cochlear implants and later, auditory osseointegrated (Baha ) implants. Cochlear established the direct Billing Service to assist recipients with the complexities of Medicare and Medicaid coverage, billing and payment for parts, accessories and services (PAS) for both implantable devices and to ensure that recipients enjoy access to the services and equipment needed to keep their implantable hearing devices working. Parts, accessories and services includes items and services such as repairs to sound processors, batteries, replacement parts, and other external hardware associated with the recipient s implantable hearing device, the Nucleus Cochlear Implant System or the Baha Auditory Osseointegrated Implant System. The Billing Service is not designed to assume insurance (except as contracted Medicare and Medicaid providers) or financial responsibility for all costs associated with a recipient s cochlear or auditory osseointegrated implant, nor can it assume responsibility for the coverage limitations of any federal, state or commercial health plan. Cochlear s Billing Service is designed primarily to support Medicare and Medicaid recipients, and works with commercial health plans only under specific circumstances such as coordination of benefits (COB); COB usually involves primary coverage through a commercial health plan and secondary coverage through a State Medicaid plan. An exception is the purchase, upgrade or replacement of sound processors for recipients covered only by commercial health plans. Cochlear s one time agreement (OTA) program facilitates the submission of claims for sound processors if certain conditions are met, for example, confirmed coverage for a new sound processor, application of in-network benefits and assignment of benefits (or paying Cochlear directly). Device recipients eligible to participate in Cochlear s Billing Service program must: 1) Have been implanted with a Cochlear America s Nucleus cochlear implant or a Baha auditory osseointegrated implant, 2) Be currently covered, or covered at the time the service or part was provided, by Medicare and/or Medicaid. 3) Be a resident of the United States or US Territories. 4) Be willing to comply with Medicare, Medicaid, commercial health plan (if applicable) and/or Cochlear America s referral processes. Working with Medicare or Medicaid requires cooperation among the recipient, the treating clinician, and Cochlear Americas: Recipient: Recipients must understand their Medicare and/or Medicaid benefits. Cochlear will help navigate these governmental programs, and their limitations, as they apply to specific recipient need; however, recipients should be familiar with the fundamental concepts of Medicare/Medicaid programs for the external parts and repairs associated with their implantable hearing devices. For Medicare beneficiaries, at the time of purchase recipients should be prepared to pay Cochlear the co-payment (usually 20% of the Medicare fee schedule) associated with the item or service ordered. Recipients should work with their professional health care provider to follow Cochlear referral procedures and document medical necessity. Clinician: The treating clinician must establish and document the medical necessity of the service or item needed by the recipient. This may require the completion of a certificate of medical necessity or other supporting documentation. They must also comply with Medicare, Medicaid, and Cochlear s referral processes.

5 Cochlear Americas: Cochlear will comply with all Medicare and Medicaid coverage and billing guidelines, and will submit a claim in a timely fashion. Cochlear will also work with the recipient, the clinician and the health plan to facilitate COB requirements based upon individual customer situations. Cochlear welcomes constructive comments regarding products and services from implant recipients, families or their representatives. Cochlear Americas encourages its recipients to contact the company directly regarding complaints or grievances concerning Billing Service activities by using the following toll free number: Calls will be handled in a responsive manner and in compliance with accreditation standards. Additionally, recipients may file a complaint or grievance regarding Cochlear s complaint handling policy and procedures with the Accreditation Commission for Health Care, Inc., When a product or repair is needed, the recipient or clinician may contact Cochlear Americas by mail, fax, telephone or . Cochlear will verify the recipient s eligibility to ensure the recipient is currently covered. Upon successful verification and the timely completion of preauthorization and medical necessity requirements and procedures, Cochlear will ship the product, or if on backorder, will provide a shipping date. Once the product has been shipped, Cochlear will submit a claim to Medicare, the State Medicaid program, or the recipient s commercial health plan in the case of COB or if the recipient is eligible to participate in Cochlear s OTA program. Although we do not provide live support 24x7, messages left on the telephone numbers below will receive a response within two business days. For additional information or questions regarding the direct Billing Service, or to order a Cochlear Americas parts catalog with pricing, please contact: The Billing Service Customer Service (Order/entry) Monday Friday from 8am - 5pm Mountain Time (telephone) (fax) Monday-Friday from 7am 5:30pm Mountain Time (telephone) (fax) Cochlear Americas East Peakview Avenue Centennial, CO (toll free) (voice) BSD001 Iss1 FEB09

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8 MEDICARE DMEPOS SUPPLIER STANDARDS Note: This is an abbreviated version of the supplier standards every Medicare DMEPOS supplier must meet in order to obtain and retain their billing privileges. These standards, in their entirety, are listed in 42 C.F.R (c). 1. A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements. 2. A supplier must provide complete and accurate information on the DMEPOS supplier application. Any changes to this information must be reported to the National Supplier Clearinghouse within 30 days. 3. An authorized individual (one whose signature is binding) must sign the application for billing privileges. 4. A supplier must fill orders from its own inventory, or must contract with other companies for the purchase of items necessary to fill the order. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs, or from any other Federal procurement or non-procurement programs. 5. A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental equipment. 6. A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable State law, and repair or replace free of charge Medicare covered items that are under warranty. 7. A supplier must maintain a physical facility on an appropriate site. 8. A supplier must permit CMS, or its agents to conduct on-site inspections to ascertain the supplier s compliance with these standards. The supplier location must be accessible to beneficiaries during reasonable business hours, and must maintain a visible sign and posted hours of operation. 9. A supplier must maintain a primary business telephone listed under the name of the business in a local directory or a toll free number available through directory assistance. The exclusive use of a beeper, answering machine or cell phone is prohibited. 10. A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers both the supplier s place of business and all customers and employees of the supplier. If the supplier manufactures its own items, this insurance must also cover product liability and completed operations. 11. A supplier must agree not to initiate telephone contact with beneficiaries, with a few exceptions allowed. This standard prohibits suppliers from calling beneficiaries in order to solicit new business. 12. A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare covered items, and maintain proof of delivery. 13. A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts. 14. A supplier must maintain and replace at no charge or repair directly, or through a service contract with another company, Medicare-covered items it has rented to beneficiaries. 15. A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries. 16. A supplier must disclose these supplier standards to each beneficiary to whom it supplies a Medicare-covered item. 17. A supplier must disclose to the government any person having ownership, financial, or control interest in the supplier. 18. A supplier must not convey or reassign a supplier number; i.e., the supplier may not sell or allow another entity to use its Medicare billing number. 19. A supplier must have a complaint resolution protocol established to address beneficiary complaints that relate to these standards. A record of these complaints must be maintained at the physical facility. 20. Complaint records must include: the name, address, telephone number and health insurance claim number of the beneficiary, a summary of the complaint, and any actions taken to resolve it. 21. A supplier must agree to furnish CMS any information required by the Medicare statute and implementing regulations. 22. All suppliers must be accredited by a CMS-approved accreditation organization in order to receive and retain a supplier billing number. The accreditation must indicate the specific products and services, for which the supplier is accredited in order for the supplier to receive payment of those specific products and services (except for certain exempt pharmaceuticals). 23. All suppliers must notify their accreditation organization when a new DMEPOS location is opened. 24. All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare. 25. All suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation. Palmetto GBA National Supplier Clearinghouse P.O. Box Columbia, South Carolina (866) A CMS Contracted Intermediary and Carrier

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