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A. Reimbursement Scenarios:

B. Consumer Reimbursement With or Without Physicians Prescription

1. Consumer purchases FLEXTEND®.

2. Consumer obtains billing forms from their insurance carrier and bills insurance company along with a copy of:

3. FLEXTEND® Product Description.

4. Billing code.

5. Product invoice (If needed).

6. Medical Necessity or Physicians Prescription

C. Hospital and Clinic Reimbursement With Doctors Prescription.

1. Doctor writes a prescription for FLEXTEND®.

2. Clinic bills patients insurance along with a copy of:

3. Patient chart notes.

4. FLEXTEND® Product Description.

5. Billing code (See Section 'C' Below).

D. Hospital and Clinic Reimbursement Without Doctors Prescription.

Clinics purchase FLEXTEND®.

Clinic bills patients insurance along with a copy of:

Patient chart notes.

FLEXTEND® Product Description.

Billing code.

Product invoice (If needed).

Medical Necessity

E. Third-Party Billing:

Doctor writes prescription for FLEXTEND®.

Third party representative faxes company name, employee name, and invoice/order to Balance Systems Inc. (BSI).

BSI bills third party agency for FLEXTEND®.

BSI sends glove directly to patient.

Payment due by third party agency upon receipt of invoice.

F. FLEXTEND® Is Billed Using The Following HCPCS Codes:

• L-3912: WHFO flexion glove w/ elastic finger control

• L-3999: Unlisted procedure for upper arm / limb orthosis.

• L-3984: Upper extremity fracture orthosis, wrist.

• E-1399: Swanson finger crush.

 SEND THE FOLLOWING INFORMATION TO INSURANCE COMPANY Via REGISTERED MAIL

• 1. PRESCRIPTION: Print Product Description & send to Insurance Company with COPY of FLEXTEND invoice, Medical Necessity and/or Physician's Prescription.

• 2. NO PRESCRIPTION: Print the Medical Necessity form and have a healthcare professional fill it out.

• 3. Send to insurance company along with copies of the FLEXTEND Invoice and Product Description. (only if you do not have a Physician's Prescription)

 INSURANCE COMPANIES THAT HAVE REIMBURSED CLINICS & SELF-BILL PATIENTS

QualMed (HMO)

Blue Cross / Blue Shield

Johnson & Culbertson (Workers Comp.)

Washington Hospitals (Workers Comp.)

Tri-Care (Champus)

Associated Administrators (Regence / Private)

Labor & Industries

O.D.S. Health Plan

Aetna Life (Assoc. w/ Medicare)

Adventist Risk (HMO / Private)

PacifiCare (HMO)

Regence (HMO)

Safeco (Workers Comp.)

SAIF (Workers Comp.)

Humana

First Option Health Insurance

Federal Workers Comp.

State Fund Workers Comp.

Prescription Management Services, Inc.

Republic Indemnity Company of America

Chubb Services Corporation

Safeway Risk Management

Kemper Insurance

Genex Services

Fremont Compensation

Principal Life Insurance Company

Medicare Part-B

Arizona Foundation for Medical Care

NOTE This is only a partial list of Insurance Companies that provide reimbursement.