Paying for COOLIEF

We know that when considering any medical procedure, cost matters, so we want to arm you with information before you talk with your specialist. Answer a few questions below to help find the information you may be looking for.

I have commercial insurance

If you’re using commercial insurance, be sure to review your insurance carefully. Find out which services are covered and which are not.

You should contact your health plan to determine coverage as well as your estimated out-of-pocket expenses before getting the COOLIEF procedure.

In some cases, you may need prior authorization from your insurance.

I’m paying for COOLIEF out of pocket

There are many options for paying for COOLIEF out-of-pocket:

Decrease Procedure Costs as Much as Possible

If you are paying for COOLIEF yourself, try to determine if and how you can best decrease the cost before you have the procedure. First, find out how much each of the providers (physician, facility, and anesthesia) charge for their associated services. Explain that you will be paying out-of-pocket and in some cases, you may be able to negotiate a lower price.

For example, sometimes using a surgery center instead of a hospital can result in lower facility costs. The people who work in billing will be most likely to know how to save you money. In fact, the billing department may be the best resource for financial and savings options.

Health Savings Account

A Health Savings Account can help you save and pay for healthcare expenses tax-free. An HSA is only available with a high deductible health plan. You can save money in your HSA account before taxes and use the funds to pay for eligible healthcare expenses. You don’t pay taxes when you take money out of your HSA to pay for eligible health-related expenses. This includes healthcare expenses your health plan doesn’t cover.

To see if you qualify for an HSA, contact your employer’s Human Resources department or visit the IRS’s website.

Payment Plans for Procedures

Some surgeons and hospitals offer payment plans for their services when you are paying for the procedure yourself.

Some payment plans are a formal agreement of monthly payments in order to pay for the expenses of your procedure. In other cases, the payment plan is considered a loan from the healthcare provider of hospital.

Healthcare Credit Cards

Medical credit cards can provide an option for payment when you need health care services or procedures and can’t pay for them right away or they may not be covered by insurance.

For providers, this option allows their patients to get the treatment they need without delay. The card issuer pays the charges up front, while you can pay a little bit each month to get the necessary treatment while being able to manage the expense. There are various companies that offer healthcare credit cards.

I have Medicare

COOLIEF may be covered by Medicare and by certain private payers. However, it is important that you and your doctor confirm with your health insurance provider to determine if your procedure is covered.

At this time, traditional Medicare does not require prior authorization and does not allow for predetermination review. Work with your physician’s office to determine your eligibility for coverage and benefits under Medicare for COOLIEF (cooled thermal radiofrequency ablation).

Medicare Advantage plans must offer the same benefits as defined by traditional Medicare, but often cover additional services. Medicare Advantage plans may have policies for prior authorization or predetermination. Work with your physician’s office in contacting your Medicare Advantage plan to determine your eligibility and coverage for COOLIEF.

Do you need prior authorization or predetermination for COOLIEF?

Most health plans require doctors to seek advanced approval for most outpatient surgeries, to verify coverage and benefits. This must be done in a specific time frame to provide applicable coding and proof of medical necessity for the procedure.

What is prior authorization?

Prior authorization (sometimes called prior approval or precertification) is the determination of the medical necessity and appropriateness of a specific treatment as a requirement by your insurance provider. While prior authorization does not guarantee that the procedure is covered, if you don’t get preauthorization, you might not get reimbursed. If all the necessary information is submitted for review, the health plan will issue a prior authorization number. The process for getting prior authorization can average from five to thirty days.

Coverage of COOLIEF varies by insurance plan, so contact your health plan provider and ask if they require prior authorization. If they do, your physician’s office may be able to assist you in the process.

What is predetermination?

Predetermination is a voluntary, written request for review of treatment or services, including ones that may be considered not medically necessary, investigational, experimental, or unproven. However, in this review process, your insurance benefit may be calculated before you have the procedure done and the costs may be more upfront. Unlike prior authorization, predetermination is offered by many health plans as an optional review process. Most predetermination requests take an average of 30–45 days to review.

Coverage of COOLIEF varies by insurance plan, so contact your health plan provider and ask if they will provide a voluntary predetermination review. If they will, your physician’s office may be able to assist you in the process.

Do you need assistance with prior authorization or appeal?

COOLIEF* Patient Access Program

What is the COOLIEF* Patient Access Program?

Avanos has partnered with PRIA Healthcare to work directly with you, your provider, and your insurance company to obtain an approval for the COOLIEF* procedure, and to appeal any service denials until a final decision is determined. An approval cannot be guaranteed; however, we will continue to work on your behalf until all avenues are exhausted.

About PRIA Healthcare

The COOLIEF* Patient Access Program services are brought to you by Avanos and managed and operated by program partner PRIA Healthcare, an experienced third-party provider of patient access services.

The above information is provided as guidance only and does not constitute reimbursement or legal advice. It is not intended to increase or maximize reimbursement by third party payers. It is always the provider’s responsibility to determine medical necessity for a procedure, including number of levels/nerves denervated (if applicable), and to submit appropriate codes, charges, and modifiers for services that are rendered. Avanos Medical recommends that you consult with your payers, reimbursement specialists and/or legal counsel regarding coding, coverage and reimbursement matters.

Prior Authorization & Appeals Process

The COOLIEF* Patient Access Program will increase your access to treatment through the submission of comprehensive patient requests for prior authorization, internal patient-based appeals, up to, and including, an external review.

Request For Prior Authorization

Your healthcare provider will provide clinical documentation to support a letter of medical necessity to your insurance plan requesting prior authorization for the COOLIEF* cooled radiofrequency treatment. If your plan approves, no further action is required, and the procedure may be scheduled.

This process may take 15-30 days once the request is received.

The Internal Appeals Process

If your plan denies your prior authorization request, a COOLIEF* Patient Access Program Case Manager will submit an appeal letter and your clinical records on your behalf in an effort to demonstrate medical necessity. Our team will request up to two levels of internal appeals, however your plan may only require one level. If the plan approves, no further action is required, and the procedure may be scheduled.

This process may take 30-45 days after an appeal is submitted. If a second internal (Level 2) appeal is available, it may take an additional 30-45 days.

Your Right To An External Appeal

If your plan denies your internal appeal(s), you may have the right to request an External Review with an Independent Review Organization (IRO). A COOLIEF* Patient Access Program Case Manager will facilitate this process on your behalf. The decision of the IRO is binding.

This process may take 45-60 days once the external review request is submitted.

Please know that our team will continue to work diligently with you, your physician, and your insurer to obtain authorization for the COOLIEF* cooled radiofrequency treatment. We ask you to please be patient throughout the authorization and appeals process as it may take anywhere between 1-4 months from when your prior authorization is initially submitted. If you and your physician decide that the COOLIEF* is right for you, we stand ready to assist you.

What to do if you’re denied coverage

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Know your rights

The Affordable Care Act ensures your right to appeal health insurance plan decisions. Under this law, if your health plan denies or refuses to pay for care, you have the right to appeal the decision through the health plan’s internal review process.

If you are denied coverage, health plans are required by law to tell you why. You also have the right to file an internal appeal, and your insurer can give you instructions on how to submit the appeal request, the deadline by which to submit the appeal request, and the availability of a Consumer Assistance program (in some states).

There are a few reasons why your health plan may deny your proposed treatment, including:

  • Services are not considered medically necessary or appropriate in a specific health care setting or level of care
  • The health plan considers the treatment to be investigational, experimental, or unproven
  • The service requested is not a covered benefit under the plan
  • The claim was not filed in a timely manner

Preparing for an appeal

If your claim is rejected, you can file an internal appeal. This is when you ask your insurance company to do a full and fair review of its decision. Make sure you complete all forms required by the health insurance plan. The COOLIEF team can assist you with this process at 1-844-4-AVANOS. If your state has a Consumer Assistance Program, they can also help file on your behalf. Several internal appeals may be needed before you can move on to an external appeal.
Information on appealing health plan decisions
Find local help for your appeals

Work with your insurance provider to go through the necessary steps to file an appeal. In general, most health plans follow the process similar to the steps listed below.

Request for Reconsideration

First-level appeals are usually reviewed by your health plan’s Appeals Department. The medical director who was involved in the denial may also be involved. Your physician may also request to speak with the medical director as a part of a “peer-to-peer” discussion in order to challenge the denial and have it overturned.

Elevate the appeal

Second-level appeals are reviewed by medical directors and Appeals Department staff that were not involved in the original decision for denial.

Independent External Review

Third-level appeals are usually completed by an independent third party (outside the health plan) who enlists the assistance of a physician who is board certified in the same specialty as the requesting physician. External review means the health plan no longer gets the final say in whether or not to cover the service.

Begin your appeal

Gather information from as many sources as you can. Some of the resources that may guide you are:

  • Your benefits handbook from the health plan. This document should identify timely filing requirements for appeal submissions, who to contact, and the best way to reach them
  • If you do not understand the information in your handbook or understand the information provided in the denial letter, contact the customer service phone number on the back of your insurance card for additional assistance
  • Your physician’s office may be able assist you in the appeal process or supply you with additional clinical information supporting your appeal request
  • Your employer’s Human Resources representative may also serve as your advocate during the appeal process

Information to include in your appeal

  • A letter of medical necessity (LMN) from your treating physician. The LMN helps to explain why the proposed treatment should be approved and will detail any prior treatments that have been tried and failed. Download a sample appeals letter
  • Medical records from the treating physician
  • Your own personal narrative that explains why you need the proposed treatment
  • Any additional support you can find (such as medical articles, etc)

Pay attention to appeal timelines

Each health plan has appeal timeline requirements, and it’s important to make sure you follow up with the health plan after you submit your appeal packet until you have a determination. The health plan is more likely to move your appeal through the appeals process if you are diligent about your request.

File an external review

If coverage has been appealed but still denied, you have the right to an independent, third-party review of your case. If your state has a Consumer Assistance Program, they can help file on your behalf.

Get a sample appeal letter

This letter is only an example.

Please edit this letter to suit your needs and replace bolded sections with the appropriate information. Remove this portion before submitting to your insurance company.

Find a specialist

There are COOLIEF*-trained specialists all across the country. Interested in an appointment?

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We're Going Live!

Join us on Facebook Live to learn more about COOLIEF* Cooled RF from a doctor who performs the procedure and a patient who's had it done. Sign up to be the first to know when the events will take place. You can also submit a question to hear your answer in real time.