Amgen - Medical Professionals

Coding and Claims Processing

Forms and Documents

The information below includes a directory of downloadable sample forms and documents to support successful claims submissions — including examples of claim forms and potential codes that may be appropriate when billing for Neulasta^® (pegfilgrastim) and related services. Properly coding your claim forms will help facilitate timely claims processing and reduce the risk of having claims denied.

Physicians or providers are responsible for selecting the appropriate codes used in filing a claim. Codes should be based on the patient's diagnosis and the items and services furnished by the physician or the provider.

Internal Approval Memo

Billing Instruction Sheet, Physician Office

Billing Instruction Sheet, Hospital Outpatient

Statement of Medical Necessity for Neutropenia Therapy

Sample Letter of Medical Necessity

Sample Letter of Appeal

Sample Letter to Local CAC Member

FDA Approval Letter

NDC Billing Sheet

Fact Sheet

Authorization to Disclose Health Information

Neulasta^® Insurance Verification Request Form

Issue Briefs

Internal Approval Memo

Internal Approval Memo

Billing Instruction Sheet, Physician Office
Form CMS-1500

Most physician offices use the CMS-1500 form (or the electronic equivalent) to submit claims to local Part B Medicare carriers, state Medicaid programs, and many commercial insurers.
Infrequently, commercial insurers require specific, customized claim forms.

		CMS-1500 Form Example
		CMS-1500, Physician Office Billing Instruction Sheet

Billing Instruction Sheet, Hospital Outpatient
Form UB-04

Most hospitals use the UB-04 (CMS-1450) form (or the electronic equivalent).
Infrequently, commercial payors require specific, customized claim forms.

		UB-04 Example
		UB-04, Hospital Billing Instruction Sheet

Statement of Medical Necessity for Neutropenia Therapy

Some insurers will require additional information justifying the medical necessity of Neulasta^® (pegfilgrastim) therapy.
Statements of Medical Necessity provide basic information about an individual patient's condition.

Statement of Medical Necessity for Neutropenia Therapy

Sample Letter of Medical Necessity

Letters of Medical Necessity provide a detailed explanation of why Neulasta^® therapy is appropriate for the medical condition described.
The attached Sample Letter of Medical Necessity provides a detailed explanation of why Neulasta^® therapy is appropriate for the medical condition described as well as potential rationale statements for communications with insurers.

Sample Letter of Medical Necessity

Sample Letter of Appeal

If an insurer denies a claim as "not medically necessary," it is up to the physician/provider to demonstrate the medical necessity of the treatment.
In the case of Medicare, it may be appropriate/necessary to submit a written appeal to the denied claim, providing written justification on why Neulasta^® (pegfilgrastim) was used.

Sample Letter of Appeal

Sample Letter to Local CAC Member

Sample Letter to Local CAC Member

FDA Approval Letter

		FDA Approval Letter

NDC Billing Sheet

NDC Billing Sheet

Fact Sheet

Fact Sheet

Authorization to Disclose Health Information

Authorization to Disclose Health Information

Neulasta^® Insurance Verification Request Form

Neulasta^® Insurance Verification Request Form

Issue Briefs

		Medicare Part D (Oncology)
		Patient Support (Oncology)
		Hospital Outpatient (Oncology)

*CPT^® five-digit codes, nomenclature, and other data are ©2005 American Medical Association. All rights reserved. No fee schedules, basic unit, relative values, or related listings are included in CPT^®. The AMA assumes no liability for the data contained herein.

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Neulasta® Indication and Important Product Safety Information

Neulasta® is indicated to decrease the incidence of infection, as manifested by febrile neutropenia, in patients with nonmyeloid malignancies receiving myelosuppressive anticancer drugs associated with a clinically significant incidence of febrile neutropenia.

Important Product Safety Information

Splenic rupture (including fatal cases), acute respiratory distress syndrome, and sickle cell crises have been reported. Allergic reactions, including anaphylaxis, have also been reported. The majority of these reactions occurred upon initial exposure. However, in rare cases, allergic reactions, including anaphylaxis, recurred within days after discontinuing anti-allergic treatment.
In a placebo-controlled trial, bone pain occurred at a higher incidence in Neulasta®-treated patients as compared to placebo-treated patients (31% vs 26%). The most common adverse events reported in either placebo- or active-controlled trials were consistent with the underlying cancer diagnosis and its treatment with chemotherapy, with the exception of bone pain.

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