GeneSight® Billing Guide for Patients GeneSight® is a genetic test that helps healthcare providers take a personalized approach to prescribing medicine for patients. Because genes influence the way a person’s body responds to specific medications, they may not work the same for everyone. The GeneSight technology is clinically proven and based on pharmacogenomics, the study of genetic factors that influence an individual’s response to medication treatments. Using DNA gathered with a simple cheek swab, GeneSight analyzes a patient’s genes and provides individualized information to help healthcare providers select medications that better match their patient’s genes. Insurance Coverage • Medicare – No out-of-pocket expense for individuals* • Medicare Advantage – Patient co-pay and/or deductible may apply • Medicaid – No out-of-pocket expense for individuals* (Not available in all states) • Workers’ Compensation – No out-of-pocket patient expense when pre-approved • Commercial or Private Insurance – Patient co-pay, co-insurance, deductible and/or unpaid balance due may apply. Deductibles may be significant in High Deductible Health Plans (HDHPs). We recommend you contact your health insurance plan directly to determine your out-of-pocket cost for GeneSight (i.e., conducting a benefits investigation). Patient Responsibility UNTIL ANNUAL DEDUCTIBLE MET CO-PAY / COINSURANCE Yes Yes Commercial Insurance – in-network Yes Yes Commercial Insurance – out-ofnetwork Yes Yes PAYER TYPE / PATIENT RESPONSIBILITY UNPAID BALANCE DUE** FINANCIAL ASSISTANCE PROGRAM ELIGIBLE BENEFITS INVESTIGATION RECOMMENDED Medicare* Medicare Advantage Medicaid* Veterans Administration Workers’ Compensation Yes Yes Yes Yes = No or Not Applicable *A Nominal annual deductible (Medicare) or spend down (Medicaid) may rarely apply **Cost of GeneSight test less amount paid by out-of-network commercial insurance How Does the Insurance Billing Process Work? Step 1 Provide your healthcare provider with your current insurance information. Many government and commercial insurance plans pay for all or part of the cost of GeneSight tests. Step 2 Particularly if you have commercial insurance, we recommend that you contact your health insurance plan to determine your out-of-pocket expenses for GeneSight. You will need to understand if you have in-network coverage or out-of-network coverage, co-insurance, co-pay and/or if a deductible will be due. We have developed a comprehensive GeneSight Patient Benefits Investigation Guide to help you determine your outof-pocket costs. The GeneSight Patient Benefits Investigation Guide is available at http://www.genesight.com/health-plans Step 3 Depending on the conclusion of your benefits investigation, you may want to consider our Direct Payment Option (i.e., not filing an insurance claim). Please call our Billing Department for pricing details and payment options. The decision of whether or not you want to exercise the Direct Payment Option must be indicated at the time your GeneSight test(s) is/are ordered by completing our GeneSight Direct Payment Information form. The form must accompany the sample for the test to be processed and payment to be made. Step 4 After your claim has been submitted to your insurance provider, you will receive a letter from Assurex Health that prepares you for the next steps in the billing process. Step 5 Your insurance provider usually processes the initial claim within a 30-45 day period. You should then receive an Explanation of Benefits (EOB) from your insurance provider. The EOB is not a bill. It is only a detailed explanation of the amount your insurance provider has covered for various components of the GeneSight test(s). If you have questions about your EOB, our Billing Department will be able to answer all of your questions. GeneSight® Billing Guide for Patients, Continued Sample EOB (not a bill) Sample Explanation of Benefits Sample Insurance Company Patient Name ID Number Claim Number Auth. Number Sample Patient 00002333 9299 019299 Service Dates LS Service Code NUM SVCS Submitted Charges Negotiated or Allowed Amt Group ID Group Name Check Date Deductible Co-Pay/ Co-Insurance 05421 Sample Group 6/12/2014 Patient Responsibility Insurance Payable Amount Totals Step 6 If your insurance provider denies coverage for the claim or makes a partial payment, our Billing Department may file an appeal on your behalf. If you receive payment for GeneSight from your insurance company, you must endorse the check and forward it to Assurex Health, Dept. CH 16854, Palatine, IL 60055. Step 7 If you have commercial/private insurance, you will receive an invoice if there is an unpaid balance due after we complete our billing process. • In-network — you will only be responsible for co-pay, co-insurance and/or the deductible that your health insurance plan has determined. Our patient financial assistance programs are not eligible to cover these patient financial responsibilities. • Out-of-network — you will receive a bill for the unpaid balance due and you may be eligible for our Financial Assistance Program (FAP) — see below for details. Financial Assistance Program (FAP) for Patients with Out-of-Network Coverage When Assurex Health files insurance claims on your behalf, and an unpaid balance is due, you will receive an invoice and application for Assurex Health’s needs-based Financial Assistance Program (FAP). If accepted into the FAP, you will receive an adjusted invoice with your maximum out-of-pocket expense. Payment can be made by check or credit card. FAP Payment Guidelines HOUSEHOLD ADJUSTED GROSS INCOME PATIENT’S RESPONSIBILITY $0 to $50,000 $20 $50,001 to $75,000 $50 $75,001 to $100,000 $100 $100,001 to $150,000 $200 Over $150,000 FAP does not apply. Patient has responsibility for unpaid balance due. All terms of the Financial Assistance Program are subject to change. The program is only available for patients with valid insurance that is out-ofnetwork when the test is administered and will be processed only after the claim with the insurance company has been resolved. This program is not available for patients who are eligible for a state or federally funded healthcare program (e.g. Medicare, Medicaid, TRICARE®, state assistance programs, etc.). This program may not be available in all states. Other restrictions may also apply. Questions To learn more about cost and reimbursement for the GeneSight test, please contact our Billing Department: PHONE E-MAIL WEBSITE 888.496.2391 [email protected] www.genesight.com ©2014 AssureRx Health, Inc. All Rights Reserved. Assurex Health is a DBA of AssureRx Health, Inc. Assurex and GeneSight are trademarks of AssureRx Health, Inc. All registered trademarks are the property of their respective owners. GSAP.009147