Control Bionics - Medicare Funding Packet...Bionics to release information related to my claim for funding to the Disability Law Center. I authorize payment of insurance benefits,

Funding Packet

Email: [email protected]: 1-513-322-4678

745 Center Street, Ste 303Milford, Ohio 45150www.controlbionics.com


Obtaining funding for a Speech-Generating Device (SGD) can feel like an overwhelming process. This funding packet checklist has been provided to help guide you through the funding process.

If you have any questions throughout the process, you can reach out to the Control Bionics Team toll free at 1-855-831-7521 or direct at 1-513-453-4848.

Before submitting the packet, check to verify the following required forms are included:

Client Information Form

Signed Release-Assignment of Benefits Payment Agreement Form

Physician’s prescription listing date, diagnosis, and equipment recommended

In addition to the above required forms, Control Bionics also requires the following information and documentation to be sent with the completed funding packet:

Clear copies the of the front and back of all insurance cards

Equipment Quote, provided by a Control Bionics representative or reseller

Speech Language Pathologist (SLP) evaluation

Submit the completed funding packet to:

Control Bionics Inc.745 Center Street, Suite 303Milford, OH 45150Fax: 1-513-322-4678Email: [email protected]

CONTROL BIONICSFUNDING PACKET CHECKLIST


CONTROL BIONICSCLIENT INFORMATION FORM

SECTION 1: Client Information (the person receiving the equipment)

First Name: __________________________ Middle Name: __________________________

Last Name: __________________________ Date of Birth: __________________________

Street Address: ____________________________________________________

City: __________________________ State: __________________________ Zip Code: _______

Telephone Number: __________________________ Email Address: __________________________

Marital Status: Single Married Gender: Male Female

Social Security Number: __________________________

Are you a student? Yes No Are you employed? Yes No

Current Place of residence: Home Group Home Intermediate Care/MR Facility

Hospice Assisted Living Skilling Nursing Facility

Custodial Care Facility Other:__________________________

SECTION 2: Diagnosis Information

Medical diagnosis: _______________________________________________________________________

Date of onset: __________________________

Communication diagnosis: ________________________________________________________________

Date of onset: __________________________

Is this diagnosis the result of an accident? Yes No If yes, date of accident: _____________

If yes, type of accident: ___________________________________________________________________

SECTION 3: Family Contact/Legal Guardian

Name: __________________________ Telephone Number: _________________________

Email Address: __________________________ Alt. Phone Number: _________________________

Relationship to Client: ____________________________________________________________________



SECTION 4: Speech Language Pathologist (Evaluator)

First Name: __________________________ Last Name: __________________________

Phone Number: __________________________ Alt. Phone Number: __________________________

Facility Name: ___________________________________________________________________________

Street Address: __________________________________________________________________________


Facility Phone Number: __________________________ Fax: __________________________

SECTION 5: Treating Physician (information below MUST match the included signed prescription)

Dr. First Name: __________________________ Dr. Last Name: __________________________

Practice Name: __________________________________________________________________________

Street Address: __________________________________________________________________________


Facility Phone Number: __________________________ Fax: __________________________

NPI Number: __________________________

SECTION 6: Shipping (Medicare funded devices MUST be shipped to the client’s home)

First Name: __________________________ Last Name: __________________________

Street Address: ____________________________________________________


Telephone Number: __________________________



SECTION 7: Equipment Requested

Make: _______________________ Model Number: _______________________ Price: _______





SECTION 8: Insurance Information

A copy of the front and back of all insurance cards MUST be included.

MEDICARE INFORMATION (if applicable)

Medicare Number: _______________________

PRIMARY INSURANCE (if other than Medicare)

Insurance Company Name: ____________________________________________________

Insurance Company Phone Number: ______________ Employer Name: _______________________

Policy Holder Name: __________________________

Policy Number: __________________________ Group Number: __________________________

Policy Holder Date of Birth: __________________________ Policy Holder SSN: _________________

Street Address: __________________________________________________________________________


Phone Number: __________________________

Relationship to Client: Self Spouse Parent Legal Guardian

Other: _________________________________________________________



SECTION 8: Insurance Information Continued

SECONDARY INSURANCE (if applicable)

Insurance Company Name: ____________________________________________________

Employer Name: _______________________ Policy Holder Name: __________________________

Policy Number: __________________________ Group Number: __________________________

Policy Holder Date of Birth: __________________________

Signature of Person(s) completing this form, please read and check next to each statement:

I verify that all of the information contained herein is correct and true to the best of my knowledge. I understand the information provided will be used by Control Bionics for the purpose of obtaining funding and hereby give permission to Control Bionics to release this information as required by the funding sources listed.

I understand that I may be able to rent or purchase the equipment that has been prescribed by the physician. The rental duration will be according to the manufacturers’ policy.

Signature: __________________________ Name + Relation to Client: __________________________ Date: ____________

Signature: __________________________ Name + Relation to Client: __________________________ Date: ____________

Send completed funding package to the address listed below, or fax to 1-513-322-4678 or email

to [email protected]

Control BionicsATTN: Funding Department745 Center Street, Ste 303Milford, OH 45150


CONTROL BIONICSLIFETIME RELEASE + ASSIGNMENT OF BENEFITS

Client Name: ____________________________________________________

I authorize the release of any medical or other information necessary for determining benefits payable for equipment or services and processing claims by the Center for Medicare & Medicaid Services, my insurance carrier and any other medical/insurance entity. I understand that on occa-sion, funding or reimbursement barrier are encountered. I hereby authorize, if necessary, Control Bionics to release information related to my claim for funding to the Disability Law Center.

I authorize payment of insurance benefits, including Medicare if applicable, be made either to me or on my behalf to Control Bionics for any equipment or services provided to me. Should I receive payment directly from an insurance company, I agree to endorse and forward the check and “Ex-planation of Benefits” to Control Bionics within seven (7) days of receipt to:

Control Bionics745 Center Street, Ste 303Milford, OH 45150

I understand that failure to provide this information will result in myself being held legally responsi-ble for payment in full for all equipment or services which I have been provided by Control Bionics.

I understand that I am financially responsible to Control Bionics for any charges not covered by health care benefits. I agree to notify Control Bionics of any changes made in my health care insur-ance coverage. In some cases, exact insurance benefits cannot be determined until the insurance company received the claim. I understand that I am responsible for the entire bill or balance of the bill as determined by Control Bionics and/or my health care insurer if the submitted claims, or any part of them, are denied for payment.

I understand that by signing this form, I am accepting financial responsibility as explained above for all payment for products received. This does not apply when Medicare determines the balance to be the contractor’s obligation.

I have read and understand Control Bionics’ Patient Bill of Rights and Responsibilities, the Control Bionics DMEPOS Supplier Standards, and the Control Bionics Notice of Privacy Practices.

This form MUST be signed and date below to be valid.

Client Name: ___________________________________ Date: _________________________

Signature of Client/Legal Guardian/Power of Attorney: ___________________________________

Relationship to Client: _______________________________________________________________

Witness:___________________________________ Date: _________________________

Relationship to Client: _______________________________________________________________


CONTROL BIONICSPATIENT BILL OF RIGHTS AND RESPONSIBILITIES

BILL OF RIGHTS

• Choose a health care provider.

• Have one’s property and person treatedwith respect, consideration and recognitionof client dignity and individuality. ¬

• Be fully informed in advance about the careto be provided, including any modificationsto the plan of care.

• Be fully informed orally and in writing of allcharges, including charges from thirdparties, in advance of care.

• Expect confidentiality of all informationcontained in the client/patient record.

• Be fully informed on the company’s policyregarding privacy practices.

• Be involved in your plan of care/service andpartake in the periodic development of suchplan.

• Receive care without regard to race, creed,national origin, sexual preference, age,disability, illness, or religious affiliation.

• Be fully informed on your responsibilitieslisted below.

RESPONSIBILITIES

• Take responsibility for the consequences ofrefusing care or not following instructions.

• Inform the equipment provider of anychanges to medical insurance coverage.

• Take responsibility for warranty informationand expiration dates.

• Complain and have your complaintreviewed in regards to policy, staff, orservice/care without restraint, interference,coercion, discrimination, or reprisal.

Complains may be sent in writing to:

Complaint DepartmentControl Bionics745 Center St, Suite 303Milford, Ohio 45150

Or

The Joint CommissionOne Renaissance Blvd.Oakbrook Terrace, Illinois 60181

• Have complaints or grievances regardingcare or lack or respect of property investigat-

ed without fear of reprisals.

• Become knowledgeable about your ¬healthplan coverage and options.

• Pay for any services for which you areresponsible.

• Protect the equipment from fire, water,theft, or other damage while it is in yourpossession.


CONTROL BIONICSSUPPLIER STANDARDS

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 enrollment

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 and must maintain a

visible sign with posted hours of operation. The location must be accessible to the public

and staffed during posted hours of business. The location must be at least 200 square feet

and contain space for storing records.

8. A supplier must permit CMS or its agents to conduct on-site inspections to ascertain the

supplier's compliance with these standards.

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, answering service or cell phone during

posted business hours 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 is prohibited from direct solicitation to Medicare beneficiaries. For complete

details on this prohibition see 42 CFR 424.57 (c) (11).

12. A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare

covered items and maintain proof of delivery and beneficiary instruction.

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 standards to each beneficiary it supplies a

Medicare-covered item.

17. A supplier must disclose 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.

26. A supplier must meet the surety bond requirements specified in 42 C.F.R.

424.57(c).

27. A supplier must obtain oxygen from a state-licensed oxygen provider.

28. A supplier must maintain ordering and referring documentation consistent with

provisions found in 42 C.F.R. 424.516(f)

29. A supplier is prohibited from sharing a practice location with other Medicare

providers and suppliers.

30. A supplier must remain open to the public for a minimum of 30 hours per week

except physicians (as defined in section 1848 (j) (3) of the Act) or physical and

occupational therapists or a DMEPOS supplier working with custom made orthotics

and prosthetics.

Control Bionics adheres to the following standards as required by the Centers for Medicare and Medicaid Services:

Above is an abbreviated version of the supplier standards every Medicare DMEPOS supplier must meet in order to obtain and retain billing privileges. These standards, in their entirety, are listed in 42 C.F.R. 424.57(c).


CONTROL BIONICSSPEECH GENERATING DEVICE PRESCRIPTION

PATIENT INFORMATION

Patient Name: ___________________________________________________________________________

Date of Birth: __________________________ Insurance ID: __________________________

Patient Address: ____________________________________________________

CLINICAL INFORMATION:

Medical diagnosis: _______________________________________________________________________

Communication diagnosis: ________________________________________________________________

Length of Need: Lifetime Other: _________________

Prognosis: Good with use of Speech Generating Device Other: ______________________

Date of last visit (face-to-face) to physician (must be within last 6 mo): __________________________

EQUIPMENT PRESCRIBED:

Device: _________________________________________________________________________________________

Accessory: ______________________________________________________________________________________

PHYSICIAN INFORMATION:

I have reviewed a copy of the Speech Language Pathologist’s completed Augmentative Communication Evaluation for the above report. The prescribed device and accessories are necessary to achieve the func-tional communication goals for this patient as noted in the SLP’s treatment plan. I certify that a face to face examination for the patient’s speech impairment has been documented in the patient record.

Physician’s Name :__________________________ NPI: __________________________

Street Address: ____________________________________________________


Telephone Number: __________________________ License Number: __________________

Physician Signature: ____________________________________________________ Date: _______


CONTROL BIONICSSGD Evaluation Criteria

A speech generating device (SGD) (E2500-E2511) is covered when all of the following criteria (1-7) are met:

1. Prior to the delivery of the SGD, the patient has had a formal evaluation of their cognitive and communication abilities by a speech-language pathologist (SLP). The formal, written evaluation must include, at minimum, the follow-ing elements:

a. Current communication impairment, including the type, severity, language skills, cognitive ability, and anticipated course of the impairment;

b. An assessment of whether the individual's daily communication needs could be met using other natural modes of communication;

c. A description of the functional communication goals expected to be achieved and treatment options;

d. Rationale for selection of a specific device and any accessories;

e. Demonstration that the patient posses a treatment plan that including a training schedule for the selected device;

f. The cognitive and physical abilities to effectively use the selected device and any accessories to communicate;

g. For a subsequent upgrade to a previously issued SGD, information regarding the functional benefit to the patient of the upgrade compared to the initially provided SGD; and

2. The patient’s medical condition is one resulting in a severe expressive speech impairment; and

3. The patient’s speaking needs cannot be met using natural communication methods; and

4. Other forms of treatment have been considered and ruled out; and

5. The patient’s speech impairment will benefit from the device ordered; and

6. A copy of the SLP’s written evaluation and recommendation have been forwarded to the patient’s treating physician prior to ordering the device; and

7. The SLP performing the patient evaluation may not be an employee of or have a financial relationship with the supplier of the SGD.

If one or more of the SGD coverage criteria 1-7 is not met, the SGD will be denied as not reasonable and necessary.

Codes E2500 - E2511 perform the same essential function - speech generation. Therefore, claims for more than one SGD will be denied as not reasonable and necessary.

Accessories (E2599) for E2500 - E2510 are covered if the basic coverage criteria (1-7) for the base device are et and reasonable and necessary criteria for each accessory is clearly documented in the formal evaluation by the SLP.


CONTROL BIONICSPRIVACY POLICY

Control Bionics’ aim is to ensure that all of the regulations outlined by the Health Insurance Porta-bility and Accountability Act (HIPAA) that apply to Control Bionics are followed by all employees.

Control bionics understands the importance of privacy and is committed to maintaining the confi-dentiality of your protected health information (PHI). Control Bionics may collect, receive, and securely store clients PHI. These records are used to ensure appropriate quality care and to obtain payment or funding assistance. Control Bionics is required by law to maintain the privacy of PHI, to provide individuals with notice of our legal duties and privacy practices with respect to PHI, and to notify affected individuals following a breach of unsecured PHI. This notice describes how we might use and disclose your health information. It also describes your rights and legal obligations with respect to your health information.

If you have any questions about this notice, please contact Control Bionics at (855) 831-7521.

We may use and disclose your health information in the following ways:The following categories describe the ways in which we may use and disclose your PHI. If you do not authorize Control Bionics to use or disclose your PHI for these purposes, you may revoke your authorization in writing at any time.

• Payment/Funding Assistance – PHI is primarily used at Control bionics to assist in getting fundingassistance through Medicare, Medicaid, or private insurance for Speech Generating Devices (SGDs)or advanced augmentative communications (AAC) devices and solutions.

• Referral to AAC Advocate – Control Bionics may send PHI to AAC advocates as required to aid inalternate funding sources.

• Require by Law – As required by law, Control Bionics will use and disclose your health informa-tion, but we will limit our use or disclosure to the relevant requirements of the law.

• Notification and Communication with Guardians, Caregivers, SLPs and Other Health Care Profes-sionals ¬– Control Bionics may disclose your PHI to authorized individuals. This may includecustomers, relatives of customers, caregivers, SLPs, other medical professionals and various fund-ing agencies including Medicare, Medicaid, and private insurance.

•Law Enforcement – Control Bionics mat, and are sometimes required by law, to disclose yourhealth information to a law enforcement official for purposes such as identifying or locations asuspect, fugitive, material witness or missing person, complying with a court order, warrant, grandjury subpoena, and with other law enforcement purposes.

•Worker’s Compensation – Control Bionics may release your PHI for Workers’ Compensation andsimilar programs.



•Research – Control Bionics may disclose your PHI to researchers when an institutional reviewboard that has reviewed the research proposal and established protocols to ensure the privacy orde-identification of your PHI has approved their research.

• Military – Control Bionics may disclose you PHI if you are a member of the U.S. or foreign militaryforces (including Veterans) and if required by the appropriate military authorities.

Your Private Health Information Rights

• Request RestrictionsYou have the right to request restrictions on certain uses and disclosures of your PHI by writtenrequest specifying what information you want to limit, and what limitations on our use or disclosureof that information you wish to have imposed. If you tell Control Bionics not to disclose informationto your commercial health plan concerning health care time or services for which you pair for in fullout-of-pocket, we will abide by your request, unless we must disclose the information for treatmentor legal reasons. We reserve the right to accept or reject any other request, and will notify you ofour decision. In order to request a restriction in our use or disclosed of your PHI, you must makeyour request in writing to:

Control Bionics745 Center Street, Suite 303Milford, Ohio, 45150

¨• Confidential CommunicationYou have the right to request that you receive your health information in a specific way or at a specific location.

•Inspection and CopiesYou have the right to inspect and obtain a copy your PHI that may be used to make a decisionabout you including: customer medical information, funding information, and billing records. Youmust submit a written request detailing what information you want access to and/or a copy of toControl Bionics. Control Bionics may deny your request to inspect and/or copy in certain limitedcircumstances.

•Amend or SupplementYou have a right to request that Control Bionics amend your PHI that you believe to be incorrect orincomplete. You must make a request to amend in writing, and include the reasons you believe theinformation is inaccurate or incomplete. Control Bionics may deny your requests if they do nothave the information, if they did not create the information, if you are not permitted to inspect orcopy the information at issue, or if the information is accurate and complete.



•Paper or Electronic CopyYou are entitled to receive a paper copy of Control Bionics’ Notice of Privacy Practices. You mayask Control Bionics to give you a copy of this notice at any time.

•ComplaintsIf you believe your privacy rights have been violated, you have the right to file a complaint withControl Bionics or with the Secretary of the Department of Health and Human Services. To file acomplaint with Control Bionics, contact them at (855) 831-7521.

Documents

Control Bionics - Medicare Funding Packet...Bionics to release information related to my claim for funding to the Disability Law Center. I authorize payment of insurance benefits,