BOTOXâ Headache Reimbursement Protocol

 1.     Physician discusses BOTOXâ treatments for headache/migraine with the patient and patient decides to proceed with therapy.  No appointment date is set until the insurance company has been contacted.  The patient is told that the office will contact them for appointment dates based on the time necessary to perform the insurance research.

2.     Staff calls insurance company to determine patient benefits.  (Alternative- staff contacts the BOTOXâ Reimbursement Hotline and asks for assistance in researching the patient insurance benefits-refer to Hotline Research Timelines.)

-Is BOTOXâ covered under pharmacy benefits?

-If so, an RX can be written to be filled by a retail pharmacy or specialty distributor identified by the insurance company.

3.     If BOTOXâ is covered only under major medical benefits, determine if prior authorization is necessary and how will the claim be processed.

-What is the prior authorization requirement?

-Determine patient co-pay responsibility- 80/20, or 100% coverage

-Remind patient that the claim will be processed as an office surgical procedure and therefore, the patient co-pay will be higher than an office visit.

4.     If the procedure is authorized, contact the patient for an appointment date and collect the patient co-pay responsibility.

5.     If the procedure is not authorized, and the patient wishes to proceed as a self pay, have the patient sign a waiver explaining that the insurance company may not pay upon submission of this claim. Collect full payment from the patient prior to the injection session.

-Have Medicare patients sign the ABN form to acknowledge that Medicare may not cover a migraine/headache diagnosis with BOTOXâ.

6.     File claim with medical records to support medical necessity.  If the patient is on referral, file medical records from the previous treating physician after obtaining the patients authorization to release referral records.  File letter of medical necessity to support the decision to treat.

-Summary of medications and treatments that have failed.

-Summarize the physician experience with BOTOXâ and the cost effectiveness of reduced emergency room visits, fewer medications, and fewer lost days of work.

-Explain that treatment may need to be repeated at 90-day intervals.

7.     If the claim is paid by the insurance company, the patient that paid “out of pocket” is reimbursed by the office. 

·       Medicare does not prior authorize procedures and payment will be based upon submission of an ICD-9 that is a covered diagnosis for BOTOXâ.

·       Medicare diagnosis coverage will vary by state. Migraine and headache diagnosis may not be covered by your state Medicare carrier.